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Page 136
Suggested Citation:"Part II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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 II - Final Research Report." 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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Final Research Report P A R T I I

141 S U M M A R Y Transit Health Protection and Promotion Research Transit Operator Health: Background Transportation sector employees, and transit bus operators in particular, are more likely to report hypertension, diabetes, and other serious and chronic health problems, compared to the US workforce: In a 2012 survey of 170,000 US workers, transportation workers reported the highest rates of chronic health problems, and achieved the lowest well-being index (Witters, 2013). Since the early 1950s, research has indicated that bus operators are at increased risk of metabolic syndrome, stroke, musculoskeletal disorders (MSDs), digestive problems, fatigue, and sleep disorders (Bushnell, Li, & Landen, 2011; Tse, Flin, & Mearns, 2006). Most of the health problems identified in transit bus operators are affected by a combination of factors, including genetics, health behaviors, and workplace and environmental conditions. In addition, the age, socioeconomic background, and ethnicity of many transit bus operators put them at increased risk for cardiovascular disease, diabetes, and other health problems (Kurian & Cardarelli, 2007; Norris & Rich, 2012; Sharma, Malarcher, Giles, & Myers, 2004). Transit employers recognize the importance of health and wellness, as do the workers and the unions that represent them (Davis, 2004). Health plan costs and retention issues drive much of the concern. Operator health can also affect customer service, performance, and safe operations. Transportation Cooperative Research Program (TCRP) Project F-17 was initiated to determine how transit organizations were affected by bus operator health concerns, and what practices could be identified to improve wellness and operational targets such as reten- tion. The TCRP F-17 research team comprised specialists in occupational health and safety, ergonomics, workplace health and health promotion research, health economics, and return on investment analysis. A subject-matter expert (SME) team to guide and evaluate the proj- ect output was drawn from the industry and included health promotion managers, HR personnel, medical staff, and union representatives who were also bus operators. The research team investigated common and best industry practices for health protection and promotion, particularly how transit programs integrated traditional health promotion approaches with important health and safety goals, and how workplace health protection and promotion in transit differed from other industries. The initial focus was narrowly on health and wellness. As research proceeded it became clear that operator health protection and pro- motion was a better way to describe the best practices observed, because it included all health- enhancing characteristics of the organization and the environment as well as the behaviors of the transit workers. The recommendations of transit workplace health professionals and health researchers supported this framework. Workplace Health Protection and Promotion (WHPP) is used to denote the full range of practice. Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention

142 This report describes the approaches that transit organizations in the US and Canada are taking to address the health problems faced by transit employees, including detailed prac- tices and some of the problems identified. The accompanying Transit Workplace Health Protection and Promotion Practitioner’s Guide and the Planning, Evaluation, and Return on Investment (ROI) Template provide transit organizations with tools to carry out effective transit-specific programs to protect the health of bus operators and other employees. Transit WHPP Program Structure, Targets, and Practices Historically, workplace health promotion has targeted individual behavior and disease management (Goetzel, 2012). But as these are only part of the explanation for health condi- tions, individual and disease-focused initiatives may not successfully maintain and promote health and protect workers. The National Institute for Occupational Safety and Health has collaborated with the Centers for Disease Control and Prevention to establish the Total Worker Health™ model (Centers for Disease Control and Prevention, 2013) The model’s essential elements of effective workplace programs and policies for improving worker health and well-being address the work environment, work organization, and individual health concerns. Other models in the US (McLellan, Harden, Markkanen, & Sorensen, 2012) and Europe (Burton, 2010) go farther, to include the social environment that surrounds and supports workers and organizations, and sometimes workforce development as a driver for health. Transit agencies surveyed and interviewed for this project demonstrated all of these approaches in their WHPP programs in varying degrees. Of the 238 transit locations with scheduled bus service invited to participate in the research, 67 agencies and 40 unions responded, from 93 transit agencies. Active agency health promotion programs were reported by 45 transit agencies and 15 unions, in 52 transit loca- tions. Five unions reported independent programs. More than half of the transit programs were started mainly to prevent work-related injury and illness, improve driver availability, and reduce the costs of healthcare or workers’ compensation. The main health problems reported were chronic disease and musculoskeletal problems. About half of responding transit agencies were concerned with achieving desired physical activity, diet, or tobacco use and with responses to work demands and work-family conflict, such as fatigue or stress. Top program targets included nutrition, weight management, and stress management. Budgets ranged from zero to $372,000. Activities were diverse, with widely varying individual, group, and organizational targets, from weight loss programs to subsidized treatment for CDL-related health problems to ergonomics assessments and procurement changes. They included social concerns such as charity fundraising and financial wellness. Even popular or well-funded initiatives, such as onsite gyms and health risk assessments, were not reaching more than 20 percent of bus operators in most organizations. Low participation was attributed to schedule conflict and lack of interest. Coordination, Partnership, and Integration According to most transit agency contacts in the F-17 study, their WHPP programs are well integrated with operational administrative policies and procedures and areas such as safety or benefits. The union respondents were about half as likely to agree. Many transit agency and union respondents felt that useful information was not available and decision making often took place in silos of influence, limiting the effectiveness of WHPP initia- tives. WHPP program activity often overlapped with worker health protection and related concerns such as ergonomics. Following the survey process, many respondents spoke about

143 planning to integrate their occupational health programs and health promotion activities to improve effectiveness. Both transit agency and labor contacts felt that their own organizations supported the program and made it a top priority, with less confidence in the other side of the table: most of the agency responders agreed (slightly to strongly) that upper management provided such support, as did less than half of the unions. In parallel, the majority of union survey respondents felt that union leadership supported and participated in the program, while less than half of agency respondents agreed that they did. Where reported, the role of the unions in WHPP included general support for management initiatives, an active role in the transit agency, including participating in committees and planning, purchasing equipment, and running an independent program. Agency and union respondents reported the health plan as the number one external part- ner of the WHPP program. Other resources and allies may be underutilized. Several pro- grams called extensively on local and national resources, some even participating in Centers for Disease Control and Prevention initiatives and worked with universities in implement- ing or evaluating their programs. Transit-Specific and Operations Concerns In the initial survey, route schedules were only flagged as having an impact on operator health problems by the union respondents. Scheduling was not an area that the WHPP program seemed to have an impact on. Yet in in-depth interviews and discussions, most transit agencies recognized that route schedules and tours did have an impact on health, and reported that schedules were adjusted to allow for rest, eating, and restroom use. WHPP program staff and unions were aware of health-supportive polices in related areas such as leave time, ergonomics, and a health-promoting environment. Effective influence on those policies was limited by the separation of health promotion from other departments. Almost all cited the organization of operators’ work, including schedule pressures and working alone, as a significant barrier both to program effectiveness and health improvement overall. The health impact of work organization and workplace conditions was addressed practically in return to work accommodations, assault or customer conflict prevention, and workplace health and safety inspections and other programs. These policies are sometimes implemented in coordination with the WHPP program and staff but more often independently. Only one-third of survey respondents characterized medical disqualification as an impor- tant result of bus operator health problems. Most did not see a strong connection between the identified operator health problems and turnover, and few reported concerns about driver availability on the survey. In detailed follow-up interviews, it became clear that for some transit agencies health has a significant impact on availability; however, the role of the WHPP program staff in addressing this was seen as limited. Important Targets for Transit Agencies Transit-Specific Resources Transit organizations—employers and unions—need content and approaches that make sense in the transit workplace, and specifically for transit bus operators. This could include new ways of using well-known activities, as well as innovations in practice and perspective. Despite the expressed need for a transit-specific approach to health, the F-17 research respondents generated many examples of their own tailored activities. The Tran- sit WHPP Practitioner’s Guide is designed to make those practices widely available. Many

144 respondents also wanted to establish ongoing ways to communicate with others who are active in transit WHPP. Availability and Retention Are Not at the Top of the List of Health Promotion Targets Absenteeism is the top health impact of concern identified at most transit agencies, but health promotion efforts did not significantly affect absenteeism in many agencies, accord- ing to the survey responses. In agencies reporting more comprehensive WHPP activities, and where health outcomes and availability data were analyzed, positive impacts of these activities on absenteeism were seen. As the F-17 project was developed, the costs related to retention problems, and especially concern about an anticipated loss of skilled operators in the next decades, were expected to drive workplace health promotion practice. However, retention and turnover were not widely considered to be linked to health problems, according to survey and interview contacts, who felt that retention depended more on better pre-hire screening and early super vision than on improving incumbent health. Some respondents pointed out that if the reasons for each separation are not evaluated carefully, the impact of health cannot be determined. Why employees leave transit requires further investigation by transit organizations, includ- ing the use of exit interviews, and earlier organizational support for mental and physical health concerns. Medical disqualification related to diseases that can be controlled or prevented was an acknowledged concern but not systematically addressed in most existing WHPP programs. Several agencies provide additional support or incentives to help operators achieve a com- plete commercial driver’s license (CDL) certification. They do this in part to eliminate the additional cost and lost time incurred when operators are under provisional licenses. CDL status can be a strong individual motivator for health improvement, so targeting these employees is an efficient use of resources. Trust and Collaboration Are Core Yet Underdeveloped Components of WHPP Agency and union respondents reported that bus operators often did not trust or wel- come health promotion initiatives. Participation in activities was limited. This was true even in areas that unions supported such as worksite exercise facilities. Limited participation could be related to scheduling demands and other work conflicts, as well as to the well- known and universal difficulty health promoters have in helping people to increase their physical activity (Fletcher, Behrens, & Domina, 2008; Wolin, Bennett, McNeill, Sorensen, & Emmons, 2008). Lack of trust was especially apparent for program elements that could be seen as intrusive or punitive, such as health risk assessments or insurance premium incen- tives. Because union leadership may not feel that health promotion serves their members’ best interests, the union structure remains underutilized, and unions do not have the control and influence that could produce health benefits for their members. The most successful programs identified in the F-17 research process were notable for the degree of support demonstrated by both labor and transit agency staff. In these organiza- tions, bus operators were active contributors to the planning process as well as consumers of the services. In one the health and safety issues were at least as significant as the individual program activities. In other cases the role of work organization was recognized and attempts were made to reduce the health impact.

145 A Practical Application of WHPP models 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. Work- ers 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 comprehensive WHPP approach recognizes that the environment—what the working conditions are, and how the organization functions—also affects health. WHPP programs in transit agencies that work with their partners to define and recognize the variety of contribu- tors are in a better position to correct or control health problems. Achieving health in the transit workplace starts with an assessment of employee health status and needs, followed by an evaluation of health-promoting practices and conditions and of barriers to health. Commitment from the organization, including top management and union leaders, and the building of an effective team set the stage for planning and implementing an effective program that integrates health, safety, and operational concerns. Baseline data, ongoing evaluation, and return on investment analyses guide planning and support ongoing improvement. The F-17 Transit Workplace Health Protection and Promotion Roadmap below illustrates a model for best practice developed to apply the current art and science of worksite health to the particular demands of work in the transit environment. F-17 Transit Workplace Health Protection and Promotion Roadmap.

146 The Tools Practitioner’s Guide The Transit Workplace Health Protection and Promotion Practitioner’s Guide accom- panying this report is designed for anyone involved in health protection and promotion in the transit workplace. The Guide outline is summarized in Appendix A: Roadmap and Best Practices for Transit Workplace Health Protection and Promotion. The Practitioner’s Guide is based on the National Institute for Occupational Safety and Health (NIOSH) Total Worker Health™ approach, and informed by theory-based prac- tice models such as the SafeWell Integrated Management System for Worker Health and the World Health Organization Healthy Workplace Framework and Model. Although most current programs in the transit industry focus on individual health issues and self-identify as wellness or health promotion, the growing consensus among research, government, and public health practitioners is that the best-practice workplace program is properly defined as encompassing 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. Most significantly, the approaches described in the Practitioner’s Guide rely on the prac- tical 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. Planning, Evaluation, and Return on Investment Template As a complementary tool to the Practitioner’s Guide, the Planning, Evaluation, and Return on Investment (ROI) Template was developed. It is designed to help transit organizations with program planning, tracking of program process, impact and outcomes measures, and calculation of ROI for their WHPP programs. The template offers a rich collection of tools to track and analyze program costs and direct and indirect benefits based on improvements in health status, productivity, availability, and safety, as well as reductions in absenteeism, turnover, and health insurance costs. It includes instructions, user entries, and automatically calculated outputs in an easy-to-navigate Excel spreadsheet. The template offers a universal yet customizable approach to measuring the impact and ROI of WHPP programs in transit. Conclusion “The biggest barrier is the nature of their work, their job design. As bus operators, they work on their own and are mobile rather than working in a specific location during their work day. It is difficult for them to attend training, workshops and events, etc. This is true in all aspects of their work, not just as it relates to health promotion/wellness initiatives.” Management representative The demands of transit work have been shown to contribute to health problems. At the same time, transit workers have serious health concerns that are influenced by factors that may or may not be under their control. The way work is organized can make it harder to achieve health goals. Transit employees, from hourly to top management and union rep- resentatives identify problems that may be universal. They are especially concerned about transit-specific issues. The need to address work and individual health contributors is sup- ported by health professionals in safety, health promotion and health care, and by govern- ment experts. The consistent report is that people working in transit recognize there are

147 problems. They want to do something about the problems to keep workers healthier, transit agencies more successful, and the public moving. The way to do that is to pool knowledge and resources within transit agencies and across the industry to improve the individual, organizational, and environmental conditions and resources that affect health. “We are combining programs to try to increase information and practice of healthy living. We have a Wellness Committee that brings forward programs and information. [We have a] dedicated ergonomist that helps with drivers with specific problems and the Health and Safety Committee which seeks to remove hazardous working conditions.” Union leader Trust is key. The finding that both labor and management felt they supported the aims and intentions of the WHPP program but each undervalued the commitment of the other party remained a consistent theme in follow-up interviews. It represents a critical target for improvement across the industry. Bus operator health, safety, and wellness are recognized priorities for all parties, but an acceptable model for cooperation has not yet been estab- lished in many locations. Among the most successful transit agencies investigated in the case studies, trust, respect, and commitment were expressed from all parties. This report and the supporting documents are designed to overcome the barriers and set the stage for action.

148 Introduction and Research Methods Background “An important tenet of Total Worker Health™ is that risks and our responses to them must be proportional. Highest risk occu- pations and workers require more frequent and more intense workplace heath interventions on both the health protection and the health promotion fronts. The higher risks of shift work- ers and low-wage workers are great examples. These folks often have riskier jobs, more personal health risks and less access to healthcare. 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, sup- ports, incentives and protections in these higher-risk popula- tions 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 (Chosewood, 2013). Transportation sector employees, and transit bus operators in particular, are more likely to report hypertension, diabetes, and other serious and chronic health problems, compared to the US workforce. In a 2012 survey of 170,000 US workers, transportation workers reported the highest rates of chronic health problems, and achieved the lowest well-being index (Witters, 2013). Since the early 1950s, research has indicated that bus operators are at increased risk of metabolic syn- drome, stroke, musculoskeletal disorders, digestive problems, fatigue, and sleep disorders (Bushnell et al., 2011; Tse et al., 2006). Most of the health problems identified in transit bus operators are affected by a combination of factors, including genetics, health behaviors, and workplace and environmental conditions. In addition, the age, socioeconomic background, and ethnicity of many transit bus operators put them at increased risk for cardiovascular disease, diabetes, and other health problems (Kurian & Cardarelli, 2007; Norris & Rich, 2012; Sharma et al., 2004). Transit employers recognize the importance of health and wellness, as do the workers and the unions that represent them, as explored in Transit Cooperative Research Program Synthesis 52: Transit Operator Health and Wellness Pro- grams (Davis, 2004). Health plan costs and retention issues drive much of the concern. Operator health is also likely to affect customer service, performance, and safe operations. Workplace health protection and promotion (WHPP) has been recognized as an important path to improving opera- tor health and reducing costs. TCRP Synthesis 52 reported on existing wellness programs and activities in the transit industry, presenting the results of a brief review of business, health, and research literature, surveys of 14 transportation properties, and six in-depth case studies. Most data collection took place in 2003, and the report was published in 2004. According to this study, “Within the 14 responding agencies, there is evidence of pro- active models of organizations seeking to improve operator physi- cal and psychological health and well-being. These organizations have invested in, to varying degrees, health and wellness pro- grams that focus on awareness-, education-, and behavior change- oriented activities of different types. . . . [T]hese activities include health education, exercise, stress management, employee assis- tance, nutrition, smoking cessation, maintaining mental health, cardiovascular disease prevention, and disease management pro- grams. The processes by which agencies have reached the pro- gram implementation stage vary and show the importance of creative and adaptive thinking in designing a program that fits the culture and needs of the individual organization.” A striking feature of the TCRP Synthesis 52 survey was its breadth and depth. Respondents provided information on organizational characteristics, program plans, activities, participation, impact, and evaluation. These transit agencies reported a wide array of activities and targets. The survey response was fairly strong (42 percent), but from a very small population (33 surveys distributed). The survey targets were organizations known to have health promotion programs, and thus likely to consider themselves and to be successful. As such, it describes only a segment of the range of transit industry experience and practices. C H A P T E R 1

149 The TCRP Synthesis 52 survey produced a useful snapshot of then-current practice. The programs and activities described were largely informational and educational. Only two employ- ers reported policies supporting healthy food choices, and sur- prisingly not all had tobacco use restrictions or a smoke-free environment. Evaluation focused largely on participation rates and somewhat on satisfaction, but only three of the 14 survey respondents measured changes in the health culture and the physical environment and only one documented improve- ments in knowledge, attitudes, skills, and behaviors. The data reported in TCRP Synthesis 52 seem to demon- strate a low level of involvement of unions in the health and wellness programs: only three locations reported that union leadership communicated support for the program to the members, although more had proposed such programs and signed off on them. This contrasted with the strong union involvement described in several of the case studies. The low level of reported involvement and participation suggested the need to better understand the reasons that unions and their members, and operators in general, support or avoid programs and activities. TCRP F-17: Defining Current and Best Practice for Bus Operator Health In 2011, TCRP Project F-17, “Developing Best-Practice Guidelines for Improving Bus Operator Health and Reten- tion,” was initiated to update and apply the knowledge gained from TCRP Synthesis 52. From 2011 to 2013, the F-17 research team investigated common and best industry practices for health protection and promotion. The research explored how transit WHPP programs integrated traditional health promo- tion approaches with important health and safety goals, and how WHPP in transit differed from other industries. This study was designed to catalog and assess the WHPP practices, goals, and models implemented by transportation organiza- tions. The initial focus was narrowly on health and wellness. As research proceeded it became clear that operator health protection and promotion was a more practically and theo- retically sound way to describe the best practices that were observed because it included all health-enhancing character- istics of the organization and the environment as well as the behaviors of the transit workers. The recommendations of transit workplace health professionals and health researchers supported this framework. Workplace Health Protection and Promotion (WHPP) is used in this report to describe the full range of practice, unless otherwise specified. The F-17 program data collection consisted of: • An extensive review of health and business literature; • A survey targeting 238 transit agencies and unions in the US, Canada, and Puerto Rico; • Detailed case examples developed through follow-up with survey respondents; and • In-depth case studies. 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 respondents felt contribute to improvements in operator health, absenteeism, medical disqualification, turn- over, health care costs, the work environment, and other out- comes related to operator health. A panel of nine SMEs—working transit bus operators, union representatives, and transit agency safety and wellness staff from agencies and unions in the US and Canada—helped assess the information and contribute to the development of the Tran- sit WHPP Practitioner’s Guide and the Planning, Evaluation, and Return on Investment (ROI) Template. All research phases were supported by the academic partners who represented stress and cardiovascular epidemiology, health economics, occupational medicine, and health promotion disciplines. Where the Transit Industry Stands As described in detail in Chapter 3: Findings and Applica- tions, 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 transit bus operators. All respondents took the issues of bus operator health, wellness, and safety seri- ously. Work organization and environment issues, although recognized as important to operator health, were often not addressed by the programs. Restricted silos of data, access, and influence were extensively reported to get in the way of effective program action. In comments and interviews, support for a WHPP pro- gram that addresses transit-specific health protection and promotion was strong. However, only half of the transit agen- cies responding to the survey had current workplace health promotion programs for transit bus operators, and only one out of three among smaller agencies. Organizations with pro- grams 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 aver- age for other industries. A recent Kaiser Foundation survey showed that 63 percent 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 percent of the F-17 survey respon- dents plan to start or restart a WHPP program. The majority of transit agencies with active programs fol- lowed a traditional health promotion program design, where health promotion consisted of somewhat isolated activities

150 rather than being integrated with other related programs and policies such as occupational safety and health protection, work design, and scheduling. Limited financial resources were seen as a major constraint to starting or broadening a pro- gram. But even transit agencies with the will to begin or expand sometimes lacked a systematic approach in preparing the orga- nization and planning the process. They described narrowly focused programs that may not achieve what they expect. The common thread was that transit bus operators are harder to reach than less mobile transit employees. Unions and management assessed the programs differently; each tended to report supporting such activities more than the other party. But all respondents felt strongly that joint action was essential in providing operators and other transit work- ers the resources they need to stay healthy and safe at work, and to return home the same way. Management respondents were much more confident that the organization’s policies and actions supported health than did union respondents. This disparate rating is commonly found in safety culture research (Huang et al., 2013). The survey and interview data collected from managers, operators, health promotion and safety staff, and unions show that effective health protection and promotion requires organizational support, adequate resources, data-based and collaborative planning, and ongoing evaluation and improve- ment. Although integrating health promotion and workplace health and safety concerns made sense to them, most did not have ways to do so. These transit industry contacts produced an extensive list of general and transit-specific program activ- ities and supports that agencies and unions felt had been of value or were likely to improve operator health, wellness, and retention. F-17 Project Products This project has produced a catalog of the common and innovative practices in bus operator WHPP. By comparing the models seen in practice with those described in the wider health promotion literature and practice, the F-17 research team established the outlines, targets, and effective actions for a comprehensive WHPP framework for transit employers and unions. The framework is described in detail in Chap- ter 5: From Industry Practice to Best Practice and Chapter 6: Program Evaluation and Return on Investment, and detailed in the Transit WHPP Practitioner’s Guide and the Planning, Evaluation, and ROI Template. The investigation of the F-17 project has already had an impact. During data collection, agency and union respondents often recognized potential improvements or were inspired by the discussion to reinvigorate their own programs. Several have already increased collaboration and co-sponsorships, realizing that sharing ideas helps them grow. Many sources, and in particular the group of SMEs, expressed a desire to participate in ongoing exchange of information and practice discussions addressing transit worker health protection and promotion. Research Approach The F-17 research team set out to identify and analyze programs and activities that contribute to improvements in operator health, absenteeism, medical disqualification, turn- over, health care costs, and other outcomes related to operator health. The first stage of the research cataloged and assessed the workplace health protection and promotion program practices, goals, and models implemented by transportation organizations. Data collection consisted of a literature review, a survey targeting 238 transit agencies and unions, detailed case examples developed through follow-up with survey respondents, and a series of in-depth, illustrative case studies. The program and implementation models seen in practice were compared with models described in the health promo- tion literature and practice to establish the outlines, targets, and effective actions for the final comprehensive workplace health promotion framework. After conducting follow-up interviews with agency and union contacts and performing descriptive data analysis, the research team developed: • Industry profiles of workplace health protection and pro- motion (WHPP) activities. • Case examples of all respondents with WHPP programs. • A summary rating of case respondents’ program activity. • A set of case study targets that illustrate development, imple- mentation, and assessment issues in WHPP. Survey To expand on the research initiated in TCRP Synthesis 52: Transit Operator Health and Wellness Programs, the F-17 research team including the academic consultants developed a survey to collect data on current workplace health protection and pro- motion programs or policies, current evaluation methods, and best practices. This industry-wide survey instrument was directed at wellness coordinators, union leaders, and others responsible for health and wellness activities at their transit agencies. The survey began by targeting the 22 data elements listed in the initial research statement: 1. Agency name; 2. Transit agency characteristics; 3. Employee demographics; 4. Program data gathering and analysis;

151 5. Health and wellness program budget and annual business plan; 6. Integration of the health and wellness program with other organizational functions; 7. Incentives to encourage participation; 8. Percent of employee participation stratified by job clas- sification, enrollment, and by active participation; 9. Program communication processes and activities; 10. Supportive organizational environment; 11. Scope of health and wellness activities (disease manage- ment, prevention, etc.); 12. Specific health and wellness activities offered; 13. Scheduling; 14. Policies supportive of the health and wellness program; 15. Changes in work organization; 16. Absenteeism; 17. Medical disqualification; 18. Turnover; 19. Management and union support for the health and well- ness program; 20. External partners to the health and wellness programs; 21. State and local governmental mandates for health and wellness programs; and 22. Evaluation of the program outcome and cost savings. Additional questions were added to characterize the tran- sit agency health culture, discover innovative practices, and illuminate barriers and enabling conditions. Wherever possible, questions were based on existing health protec- tion and promotion surveys as identified in the literature review. To take into account the different roles of manage- ment and union leaders in health protection and promo- tion, separate surveys for agency and union respondents were developed. The survey was vetted by the academic partners who have extensive experience in collecting health data (Landsbergis and Fisher), economic data (Levenstein) and health promotion program information (McLellan). The final versions of the survey were published in Survey Gizmo, a leading online survey engine, to be accessed by targeted stakeholders. PDF copies were also distributed upon request. The final agency and union survey instru- ments are attached to this report in Appendix C (Manage- ment form) and D (Labor form). Using the APTA 2011 Fact Book, the CUTA 2010 Fact Book, and the National Transit Database, a list of potential survey locations was created. The list included the top 50 bus agencies by ridership based on the APTA 2011 Fact Book, the top 20 Canadian agencies by ridership based on the Cana- dian Urban Transit Association (CUTA) 2010 Fact Book, a pre-selected agency list based on team knowledge of existing program activity, and 150 randomly selected agencies listed in the NTD database and the CUTA Fact Book. The final list of approximately 238 was adjusted to ensure that locations from all states were covered. An invitation to participate in the 32-question survey was distributed via email by the American Public Transit Associa- tion, CUTA, and the project team to CEOs, and by mail and email from international unions to local union presidents. Fol- low-up emails were sent and two telephone calls were made to all non-responding agencies and unions throughout the five- month data collection period. Responses from 67 agencies across the US (52) and Canada (15) were received, and from 40 agencies represented by 44 local unions (8 Canadian and 36 US), for a total of 94 different agencies, about 40 percent of the targets. 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 five agencies whose practice illustrated core concepts in designing, implementing, and assessing integrated WHPP programs. The survey response frequencies and distribution—a snap- shot of the current profile of programs within the responding transit organizations—are described in Chapter 3: Findings and Applications: A Profile of the Industry. Follow-up Data Collection and Case Examples After surveys were completed, follow-up discussions by telephone or email with 40 sources from 26 agencies were held to clarify the survey findings and expand on the health and wellness program experience of labor and management. The in-depth interview questions, used in these follow-up inter- views and vetted by the academic consultants, built on the survey questions to fill in gaps of qualitative and quantitative information not provided in the initial broad survey design. Using the survey responses and follow-up interviews, a catalog of case examples of workplace health protection and promo- tion programs was developed, which are reported on in Chap- ter 4: Case Examples and Case Studies. Survey respondents were selected as case examples if they provided follow-up agreement and contact information, included transit fixed- route transit bus operators, had a current workplace health promotion program within the last five years, and submitted a substantially complete survey or otherwise indicate involve- ment with project concerns. Although the initial plan called for focusing on locations that had demonstrated measurable changes, clearly established and quantitatively supported out- comes were in fact rare in the responding population. More significantly, many organizations had successes to describe and warnings to provide even in the absence of measured impact. Thus data collection was not limited to obviously suc- cessful programs but continued where the informant response indicated the existence of an exemplary program component.

152 The survey follow-up in-depth interview questions, quan- titative data collection questions, and case example questions are provided in Appendix E. Case Studies After a review of the case example catalog, the F-17 research team and academic partners developed a set of criteria to identify effective programs for in-depth case study investi- gation. These criteria included the minimum and preferred requirements for potential case studies. The rating process reviewed whether: • The agency had a program, rather than simply referring to the health plan or carrying out a few activities. • There was involvement throughout the organization. • The program addressed retention and other operational needs. • Evaluation data was collected. • Health outcomes data was collected. • Return on investment was calculated. • There was a person responsible for the program. • The program allowed family and/or group involvement. • The program was a stand-alone or integrated program. Ten potential case study targets were defined. A case exam- ple follow-up questionnaire was developed by the research team and academic consultants to help with the case study selection process. In-depth interviews were held with 15 sources from the 10 agencies. Six recurring themes that illustrated the path to establishing and maintaining a WHPP program were identified in this process: program initiation, health tar- gets and problem definitions, building the team, using inter- nal data to plan and adapt, maintaining effectiveness with growth, return on investment, and integration with work environment changes. Five agencies with active and effective programs that illustrated at least one of these concepts were identified and asked to participate more extensively in the case study process. Table 1 lists the case study sites, and the program area that they illustrated. The five case studies were developed through a combina- tion of site visits, email exchanges, and telephone conversa- tions. During site visits interviewers participated in health and wellness committee meetings, visited health and well- ness program facilities, and interviewed health and wellness program participants, program administrators, and union representatives. Telephone and email exchanges were used to efficiently collect data and conduct interviews. In addition to these five case studies, the F-17 research team also analyzed the combined examples of small agency respondents and particular issues facing multi-agency pro- grams offering health and wellness programs through a city, state, or county government entity. The case studies are detailed in Chapter 4: Case Examples and Case Studies. Defining Best Practices The F-17 research team used the components of best work- place health promotion practice as defined by health promo- tion researchers (Grossmeier, Terry, Cipriotti, & Burtaine, 2010), the European Network for Workplace Health Pro- motion (ENWHP), and the NIOSH Total Worker Health™ essential program elements (Centers for Disease Control and Prevention, 2013) to draft a framework for transit workplace health protection and promotion practice. Elements and components were added and edited based on the survey and interview results, the transit-specific literature, and theory considerations suggested by the SafeWell Practice Guidelines (McLellan, Harden, Markkanen, & Sorensen, 2012) and the World Health Organization model (Burton, 2010), with input from the F-17 academic partners. A summary table detailing the components, measures, and outcomes of good practice in transit agencies was compared to the library of best practices developed through the data collection, and included detailed descriptions of the practices, descriptions of specific actions, tools, resources, and references was reviewed by the TCRP Agency Name Program Area Los Angeles County Metropolitan Transit Authority (LACMTA) Getting Started—Preparing the organization and making the commitment Dallas Area Rapid Transit (DART) Building the Workplace Health Protection and Promotion Team Edmonton Transit System (ETS) Setting Targets in Transit Health Protection and Promotion Orange County Transportation Authority (OCTA) Implementing and Integrating an Effective Transit Workplace Health Protection and Promotion Program Capital Metropolitan Transportation Authority (Capital Metro) Evaluation, Return on Investment, and Ongoing Improvement Los Angeles County Metropolitan Transit Authority (LACMTA) Maintaining Effectiveness with Growth Table 1. Learning from industry practice: case studies.

153 F-17 panel. (Detailed references available on request to the principal investigator.) The final suggested components and examples of best practice were reviewed and revised by the subject-matter expert team and the academic partners. These industry best practices will be discussed in detail in Chapter 5: From Industry Practice to Best Practice. Transit Workplace Health Protection and Promotion (WHPP) Practitioner’s Guide The Practitioner’s Guide was designed to support the development of effective health protection and promotion programs in the transit workplace. The Practitioner’s Guide contents are based on the model of health and change devel- oped by researchers, health agencies, and on-the-ground practitioners around the world. It follows national recom- mendations for workplace health protection and promotion and applies these concepts to the practical realities of the transit workplace. The main focus is on transit bus opera- tors because of the established health risks and demanding working conditions, but the concepts can be used throughout transit operations, maintenance, and other areas. Even when they address safety concerns, the Practitioner’s Guide and the WHPP program cannot replace a Safety Management System approach or take on the work of the organization’s Environ- ment, Health, and Safety department; Human Resources; and all the other disciplines that contribute to an effective organi- zation. The goal is to bring together the issues across transit workplaces that affect health, safety, and well-being, and to engage the people who can make a difference. Planning, Evaluation, and Return on Investment (ROI) Template The F-17 research team collected examples of existing evaluation tools and cost-benefit calculators from litera- ture sources, websites, and the participating survey and case study locations. These resources included program outcome tracking tools, survey instruments, methods for estimating program costs, and return on investment (ROI) calcula- tors. Practical measurable indicators of success identified by industry respondents included health outcomes measures, health care costs, safety, absenteeism, productivity, and employee satisfaction. Using these resources, the F-17 research team developed a list of measures for program planning, impact and outcomes tracking, and cost and benefits for ROI analysis of workplace health promotion programs, as applicable to transit and espe- cially bus operator programs. These were built into Excel spreadsheets to incorporate user entries and automatically cal- culate outputs. In the Planning, Evaluation, and ROI Template, sample data is provided that allows users to explore the template without deploying real data. The program cost and financial benefits totals are transferred to a summary sheet with return on investment calculations. Additional tools and resources are linked to in the template, including reference articles, pro- gram rating guides, questionnaires, and online calculators. Subject-Matter Experts For products developed in this project to be technically robust and genuinely valuable to transit stakeholders, the F-17 research team recognized the importance of involving subject- matter experts (SMEs) from the transit industry throughout the process. Using survey and follow-up interview responses, four union and five agency SMEs were recruited to provide input on the library of best practices and criteria for effective programs. The SMEs were identified based on the effective- ness of the health and wellness programs at their respective agencies, their own knowledge and competencies, and their willingness to participate and provide input. They partici- pated in meetings to discuss the draft of the library of best practices and to discuss best and innovative practices at their locations. The subject-matter experts and academic partners helped finalize the best practices for the Practitioner’s Guide. Subject-matter experts were also involved in the develop- ment and testing of the Planning, Evaluation, and ROI Tem- plate. The SMEs were asked to review the template for any inadequacies or missing components. Management SMEs were asked to input data into the template to test the function- ality and ease of use of the template. Based on their comments and reviews from the project health economist and other aca- demic partners, the Planning, Evaluation, and ROI Template was finalized and integrated into the Practitioner’s Guide.

Literature Review Literature Search A literature search was carried out on the National Library of Medicine search engine PubMed and the business resource LexisNexis. Titles generated were reviewed if they described health promotion efforts in transportation, discussed key elements of health promotion programs such as return on investment, or described health and safety factors affecting transit bus operators. A search on “health promotion AND occupational AND bus operator” in PubMed produced 82 ref­ erences since 2000, of which 26 were relevant. A search on “bus AND health” produced 82 references since 2010, of which 32 were relevant. A review of the research bibliography col­ lected in the past by the principal investigator produced about 100 useful references, most pertaining to transportation worker health problems, health promotion practice methodology, and intervention research results in transportation and skilled trade workplaces. The project consultants provided about 20 additional references, most addressing methods and their own research practice. LexisNexis was searched for “workplace health promotion AND transportation,” producing 34 further references of which 15 were relevant. On review the literature search identified 60 citations from all data sources describing health promotion interventions and practices relevant to the transit workforce. Transporta­ tion workplace interventions were described in 35 sources. The remaining sources discussed interventions in other blue­ collar environments such as construction and health inter­ ventions directed at problems that are significant problems for transit bus operators, such as cardiovascular disease. Several hundred additional articles discussing disease epide­ miology, workplace exposures, and occupational health and safety interventions in the transit industry were also identi­ fied. The literature demonstrating the rates of illness in tran­ sit workers and related occupations research is described with examples from 54 of these sources in the next section, but a comprehensive review of the field is beyond the scope of the current report. The primary focus of this review is to sum­ marize the findings from workplace health protection and promotion approaches most relevant to bus and other trans­ portation operators. This includes some studies addressing work conditions and environment in the context of specified health targets but not the extensive literature on occupational health and safety. The evaluation and return on investment literature is discussed in Chapter 6: Program Evaluation and Return on Investment. Transit Bus Operator Health Prevalence of Health Problems Among Transit Workers Transit bus operators experience a wide range of physical and mental health problems, including chronic diseases, such as cardiovascular disease, cancer, and hypertension, disorders that have acute and chronic components, such as lower back pain and depression, and injuries resulting from assault or acci­ dents. The findings have been consistent in research carried out across decades and countries. A review of 22 articles in 1988 reported: “These studies focus on three main disease categories: (1) cardiovascular disease, including hypertension, (2) gastrointestinal illnesses, including peptic ulcer and diges­ tive problems, and (3) musculoskeletal problems including back and neck pain. The studies consistently report that bus drivers have higher rates of mortality, morbidity, and absence due to illness when compared to employees from a wide range of other occupational groups.” (Winkleby, Ragland, Fisher, & Syme, 1988). A recent review of 27 papers covering 50 years of bus operator well­being confirmed, “Early findings that bus drivers are liable to suffer ill health as a result of the job remain true today. The research has, however, demonstrated a greater understanding that specific stressors result in certain physical (cardiovascular disease, gastro intestinal dis orders, musculoskeletal problems, fatigue), psychological C H A P T E R 2 154

155 (depression, anxiety, post­traumatic stress disorder) and behav­ ioural outcomes (substance abuse). Bus driver ill health will have consequences for organisational performance in terms of employee absence, labour turnover and accidents. Stressors for bus drivers include poor cabin ergonomics, rotating shift pat­ terns and inflexible running times.” (Tse et al., 2006) The review authors point out that transit bus operators are screened frequently and may be disqualified from the occu­ pation for a variety of health problems that are common in the population at large and among other workers. The actual rates of disease related to bus operator work could be higher if those who left the occupation for related health reasons were included in the analysis. Research continues to demonstrate a high prevalence of cardiovascular disease (CVD), hypertension (HT), and dia­ betes in transportation workplaces around the world. In addition to the evidence for hypertension described in these review papers, studies have shown hypertension in transit bus operators in California (Ragland et al., 1989) and Russia (Elgarov & Zhurtova, 1998). A recent analysis assessed the prevalence of 15 diseases by industry subsector from health plan data in more than 214,000 workers in Pennsylvania. Local and interurban passenger transit employees showed the highest rates of hypertension, depression, CVD, and diabetes (adjusted for age and gender but not smoking, race, socio­ economic factors, and other potential contributors) (Bushnell et al., 2011). In 2009, 4,402 US retired transit workers had a statistically greater prevalence of CVD risk, hypertension, and diabetes, compared to national samples of blue­collar retirees ( Gillespie, Watt, Landsbergis, & Rothenberg, 2009). In a group of New York City bus drivers, there was a significant excess of death due to ischemic heart disease (Proportionate Mortality Ratio (PMR) =1.23) (Michaels & Zoloth, 1991). Diseases of the circulatory system made up the largest proportion of dis­ ease found in bus and tram operators in Croatia (Szubert & Sobala, 2005). Hospitalization related to stroke was increased by 57 percent in Danish professional drivers (Standardized Hospitalization Ratio (SHR=157), and by 40 percent in bus drivers (SHR=139), compared to the male working popula­ tion. Brazilian bus drivers were at higher risk of CVD than other workers (Neri, Soares, & Soares, 2005). Metabolic syndrome, a cluster of health indicators that pre­ dict CVD, is more common among transit bus operators than other workers. In a study of 8,500 US workers, the cohort of transport and materials handling workers including transit bus operators were found to be at the greatest risk of meeting the criteria for metabolic syndrome (Davila et al., 2010). Ele­ vated body mass index (BMI), low physical activity levels, and poor hormone function have been found in Croatian, Dutch, and Iranian transit bus operators (Proper & Hildebrandt, 2010; Skrobonja & Kontosic, 1998). Overweight and hypertension were more common in drivers than nationally demographi­ cally similar males in Poland; 68 percent of drivers who were both hypertensive and overweight were also hyperglycemic (Marcinkiewicz & Szosland, 2010). Research has indicated that some cancers are associated with transit work: New York City transit bus operators showed a higher mortality from all malignant neoplasms and from cancer of the esophagus than the US population (Michaels & Zoloth, 1991). German case­controls studies showed an increased risk, after controlling for smoking and alcohol, of esophageal cancer associated with diesel oil and gasoline exposure among trans­ portation and warehousing workers (Ahrens, Jockel, Patzak, & Elsner, 1991), and of lung cancer (Jockel, Ahrens, Jahn, Pohlabeln, & Bolm­Audorff, 1998). US transport and motor vehicle operators were at a significantly greater risk of esoph­ ageal and stomach cancers (Engel et al., 2002). There was an excess of lung cancer mortality among urban transit workers in Canada (Guidotti, 1992) and in Italy (Merlo et al., 2010). However, other studies do not support this: a recent Danish study found little evidence of increased cancer among transit bus operators, and no association between length of employ­ ment and cancer (Petersen, Hansen, Olsen, & Netterstrom, 2010). Cancer mortality was not increased among Swedish transit bus operators (Alfredsson, Hammar, & Hogstedt, 1993). Two US studies using data from the 1980s suggest that tran­ sit operators were more likely to have used tobacco than other workers (Leigh, 1996; Lipton, Cunradi, & Chen, 2008). Lung problems in addition to cancer are of concern in trans­ portation work. In an assessment of US working population data to determine the level of chronic obstructive pulmonary disease (COPD) risk by occupation, motor vehicle operators were 37 percent more likely to be diagnosed with COPD than insurance and financial workers (Bang, Syamlal, & Mazurek, 2009). The researchers found smoking to be more com­ mon among transportation operators. In an investigation of National Health and Nutrition Examination Survey (NHNES), data, transportation operators were the highest­ranking occu­ pation for cigarettes smoked per day (Leigh, 1996). A large number of studies have examined lower back, upper back, arm and neck pain, and clinical disorders in the US (Greiner & Krause, 2006), Brazil (Neri et al., 2005), Mexico (Prado­León, Aceves­González, & Avila­Chaurand, 2008), Malaysia (Tamrin et al., 2007), among others. In Israel, the 12­month prevalence of pain was elevated in transit bus operators (back 45.4 percent, neck 21.2 percent, shoul­ der 14.7 percent, upper back 8.3 percent, elbow 3.0 percent, wrist 3.0 percent) (Alperovitch­Najenson, Katz­Leurer, Santo, Golman, & Kalichman, 2010b; Alperovitch­Najenson et al., 2010a). Among a stratified random sample of 195 urban motor coach operators in California, 80.5 percent of drivers had cur­ rent back or neck pain in contrast with 50.7 percent of non­ drivers, although severe pain was comparable in the groups (Anderson, 1992). Dutch drivers had higher rates of back pain

156 (Hildebrandt, 1995). School bus drivers in Canada were more likely to have neck and shoulder problems than the general pop­ ulation (Gourdeau, 1997). Musculoskeletal problems among bus drivers, including carpal tunnel syndrome and back pain, may be caused or aggravated by motor vehicle accidents and hazardous environmental conditions (Barak & Djerassi, 1987). Bus operator health has an effect on operations as well as on the operators. As cardiovascular illnesses, musculoskeletal diseases, and other concerns for transit bus operators develop over time, work efficiency may decline, and employee absen­ teeism and onsite injuries increase (Kompier, Aust, van den Berg, & Siegrist, 2000; Kompier, 1996). Transport agencies have for decades reported their concern with the impact of poor ergonomics and poor worker health on opera­ tions (Long & Perry, 1985). Fatigue is a recognized risk for commercial vehicle accidents (Gertler, Popkin, & Nelson, 2002; Scott, 2003), but in a Turkish study only daytime sleepiness and not other symptoms were related to accidents among drivers with obstructive sleep apnea (Akkoyunlu et al., 2013). The role of other diseases in accidents, includ­ ing those that disqualify operators from a CDL, has been extensively investigated although the evidence is mixed; for example, one estimate calculated that bus operators were less likely to experience accidents related to a second myocardial infarction than other drivers (Shephard, 1998), and in Japan bus operators were less likely than other drivers to experi­ ence vehicle accidents during vascular events while driving (Hitosugi, Gomei, Okubo, & Tokudome, 2011). Overall, the financial impact of operational losses and health care costs, particularly in an aging workforce, are a major concern for transit employers and others. At the same time, researchers have developed predictive models suggesting that the cost growth can be slowed if effective risk factor modification pro­ grams are implemented (Leutzinger et al., 2000). The Impact of Conditions of Work A complex set of individual, social, organizational, and environmental factors affects worker health and influences cost and operational outcomes. Work exposures and work organization contribute to the occurrence of diseases such as CVD, hypertension, diabetes, and MSDs. For example, diesel exhaust has a direct effect on existing heart disease (Mills et al., 2007), and night work in other sectors is linked to meta­ bolic syndrome (Pietroiusti et al., 2010) and cancer (Megdal, Kroenke, Laden, Pukkala, & Schernhammer, 2005). There is literature describing work organization and environ­ mental factors affecting transit bus operators include long hours, shift work, sedentary jobs, low social capital, heavy traffic routes, poorly designed driver seats, and hostile pas­ sengers, among others (Bacharach, 2005; Kashima, 2003). In a survey of 785 bus operators in China, age, body mass index, depression, daily working hours, perceived company safety culture, and health problems were significantly associated with self­rated health. Work conditions can also affect health behaviors, so that transit bus operators who work long shifted hours have less of an opportunity to participate in the appro­ priate amount of physical activities (Szeto & Lam, 2007). Un comfortable seats and lack of back support were reported more frequently by urban bus drivers with neck pain than those without and upper quadrant pain and low­back­pain were associated with physical and psychosocial stressors among Israeli transit bus operators (Alperovitch­Najenson et al., 2010b; Alperovitch­Najenson et al., 2010a). High job strain due to the organizational risk factors of this profession can cause stress (Greiner & Krause, 2006). An increase in work­family conflict, mainly due to long work hours, has been associated with an increase in the likelihood of sickness absence (Antonio, Fisher, & Rosskam, 2009; Bacharach, 2005; Long & Perry, 1985). Work­family conflict for operators may be greatest for those caring for children (Scheller, 2011). Mental and physical stressors experienced by all workers have been associated with smoking status (Bang et al., 2009). Depression, elevated in transit workers in Pennsylvania and Canada (Bushnell et al., 2011; Guidotti, 1992) can influence overall well­being and reported health, and thus smoking may be used as a coping mechanism (Chung & Wong, 2011). Workers with high job demand and low control are at an increased risk for poor physical and psychological outcomes (Choi et al., 2010). The high work demand of transit bus oper­ ators may be associated with greater risk of diseases such as CVD (Sapp, Kawachi, Sorensen, LaMontagne, & Subramanian, 2010) and disturbed sleep (Utsugi et al., 2005). Fatigue may be affected by positive work experiences, and have an impact on healthy decision making: Motor freight workers reporting lack of job strain and greater supervisory support were more likely to achieve adequate sleep patterns and make healthy food choices (Buxton et al., 2009). Health Summary Research covering more than five decades demonstrates that transit sector employees, and transit bus operators in particular, have higher rates of many chronic diseases than other workers. In a large national survey in 2012, transit bus operators were in the top of all occupations in self­reported prevalence of obesity (#1 among all job titles), smoking (#3), limited exercise (#2), lower than recommended fruit and vegetable intake (#4), work that does not use their strengths (#2), supervisors who are not partners (#1), and they had the lowest overall well­being index (Witters, 2013). Research suggests that there is a connection between tran­ sit employment and metabolic syndrome, diabetes, stroke,

157 musculoskeletal disorders, digestive problems, fatigue, and sleep disorders (Tse et al., 2006). Most of the health problems identified in transit bus operators are affected by a combi­ nation of factors: genetics, life experience, health behaviors, and workplace and environmental conditions such as air pol­ lution, passenger assault, schedule stress, and sleep disrup­ tion. In addition, the age, socioeconomic background, and ethnicity of many transit bus operators put them at increased risk for CVD, diabetes, and other health problems (Kurian & Cardarelli, 2007; Norris & Rich, 2012; Sharma et al., 2004). Effective workplace health protection and promotion efforts in transit will need to address disease identification and man­ agement, the health environment, and the environmental and organizational contributors to operator health, safety, and well­being as well as productivity and other organiza­ tional outcomes. Health Protection and Promotion Interventions Effective Health Promotion The Centers for Disease Control and Prevention (CDC) Task Force on Community Preventive Services reviews the research literature on workplace health promotion on an ongoing basis, focusing strongly on individual health and wellness; the review does not cover occupational health protection or safety (Task Force on Community Preventive Services, 2010). As shown in Table 2, the Task Force reports convincing evidence that workplace environmental and pol­ icy 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 research reviewed focused on white collar workforce and may not apply as well in the transit environment. This analysis could not determine what, among the many educational, fitness, or other health promo­ tion components was having the observed effects on obesity. There is adequate evidence to support the effectiveness of onsite flu vaccination programs, and decreasing tobacco use with worksite policies, incentives, and competitions. Another clear message of the Task Force on Community Preventive Services was that health risk screening or health risk assessment (HRA) alone is not enough, but following HRA results with health education, referrals, and activities does improve health outcomes. According to the review, health education following HRAs can have an impact on tobacco, alcohol, and seatbelt use, blood pressure and cholesterol, days Interventions to Promote Seasonal Influenza Vaccinations Among Non-Healthcare 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 Interventions Recommended 2007 Preventing Chronic Disease Skin Cancer Prevention: Education and Policy in Outdoor Occupational Settings Insufficient Evidence 2002 Diabetes Prevention and Control: Self-Management Education 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 Decreasing Tobacco Use in Worksite Settings 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 Table 2. Task Force on Community Preventive Services recommendations and findings.

158 lost, and appropriate health care utilization, as well as on the total number of self­reported risk factors. It does not have a proven impact on fruit and vegetable intake, body composi­ tion, or overall fitness. (This may be because it is hard to show statistical significance for small changes that may be impor­ tant to health at the individual level, or because the measured interventions were not well executed, or because they do not in fact work.) Research on Health Promotion in Transportation and Related Interventions Thirty­five articles describing research on health promo­ tion interventions in the transportation sector were reviewed for this report, along with 25 articles in other blue­collar workplaces and similar settings that provide insight into the approaches that may be effective in public transit. Disease Identification and Management Health risk screening and monitoring are common in workplace health promotion programs. They are useful for making referrals for treatment, for targeting interventions to workers at risk of disease, but, as noted earlier, screening and risk assessment work in the context of effective support and counseling. Blood pressure machines were installed at bus terminals to increase hypertension awareness in school bus drivers where almost 60 percent of operators were found to be hyper­ tensive (Doyle, Severance­Fonte, Morandi­Matricaria, Wogen, & Frech­Tamas, 2010). This screening was combined with gym access, free diet consultations, and educational mailings. At follow­up, blood pressure was reduced and health behav­ iors improved: 58 percent of participants were controlled to blood pressures below 140/90 mmHg, the current stan­ dard for a commercial driver license (CDL) certification. An increased proportion of previously diagnosed hypertensive drivers reported home BP monitoring, regular exercise, and a healthy diet. Following a utility company hypertension (HT) management program, including information about medi­ cation and verbal counseling, there were significantly fewer drivers with uncontrolled hypertension, including those with diabetes, obesity, or on HT medications (Harshman et al., 2008). The study took place concurrently with changes in CDL regulations, which, by requiring tighter blood pres­ sure control requirements for certification, also may have had an impact on the levels. According to the Task Force on Community Preventive Services, screening alone is not considered an effective inter­ vention. In contrast, after being screened for heart disease risk factors 74 percent of workers from a US factory with high­fat diets reported eating a lower fat diet, 71 percent of overweight participants reported weight loss, 53 percent of sedentary participants attempted to increase physical activity, and 38 percent of smokers said they decreased or quit cigarette smoking (Wang et al., 1999). A follow­up cholesterol­related physician visit had little added clinical benefit over the screen­ ing intervention alone. The outcomes were self­reported, not measured, so it is possible that the subjects adapted their answers to behavior norms that had been communicated in the study without changing what they did. Interventions after a general screening often target those identified as higher­ risk. Following a CVD risk factor screening and counseling intervention in a Swiss factory, advanced health counseling was offered to those at moderate or elevated risk (Prior et al., 2005). High­risk participants showed a significant improve­ ment in diastolic blood pressure, total cholesterol, and smok­ ing status whereas in the low­risk group, cholesterol and BMI deteriorated. Physical Activity Increasing exercise and other physical activity is a com­ mon WHPP target because physical activity affects cardio­ vascular health and BMI and is linked to metabolic syndrome and many other health problems (Bigert et al., 2003; Davila et al., 2010). Starting in 1979, Johnson and Johnson used work­ place health promotion activities to improve the lifestyles of their 30,000 workers who participated in a 3­hour long life­ style orientation seminar for the program (Ozminkowski et al., 2002). At some worksites, exercise was done during the seminar at other locations the company provided acces­ sible fitness facilities. Among those who participated in the full program with the seminar, 20 percent of the women and 30 percent of the men reported regular vigorous activi­ ties two years later, compared with seven percent of the women and 19 percent of the men whose health was screened only. Participants who received the full health promotion intervention had increased their fitness levels (measured by lung vital capacity) 10.5 percent from baseline compared to 4.7 percent of those in the comparison group. In a random­ ized study providing enhanced fitness facilities in two of four bus garages, physical activity was not improved compared to the controls although other study interventions were suc­ cessful; the authors suggest that physical activity behavior interventions change may have limited impact among transit workers who spend most of their day outside the worksite (French et al., 2010b). Blue­collar workers and older workers may be less likely to participate in programs to increase physical activity than other workers studied (King, Glasgow, & Leeman­Castillo, 2010) despite an increased risk of related disease (Dorner

159 et al., 2006). To address this, a group of 22 operations and maintenance workers on a college campus was targeted in a 16­week exercise intervention. Public monitoring, work­ shops, and competition and incentive­based activities were successfully used to promote wider participation. Compared to baseline, fitness level and confidence in a participant’s abil­ ity to exercise regularly significantly increased, and overall body weight significantly decreased, although the increase in physical activity was not significant. The researchers suggest carefully considering the financial, work organization, and other barriers to physical exercise in this group. Some worksite environmental resources used to promote physical activity are not applicable to all worksites. A review of interventions to increase stair climbing in the workplace concluded there was little evidence supporting successful increases in stair climbing, not least because many work­ places’ access to stairwells is limited. (Eves & Webb, 2006). Tobacco Use Bus operators are more likely than other workers to smoke, and smoking may be an attempt to deal with the work stress demands of the job (Chung & Wong, 2011). Worksite­based strategies to encourage smoking cessation include facility smoking bans, group education, and motivation sessions, nic­ otine replacement therapy (NRT), participatory approaches, and multiple outcome measure interventions (ENWHP, 2008; Maheu, Gevirtz, Sallis, & Schneider, 1989; Okechukwu, Krieger, Sorensen, Li, & Barbeau, 2009; Quintiliani, Yang, & Sorensen, 2010; Sorensen et al., 2010). Most programs did not directly address other types of tobacco use. In Barcelona, a workplace­smoking ban and a company­wide smoking cessation support workshop aimed to decrease smok­ ing activity in transit bus operators; the proportion of smok­ ers decreased 10 percent after five years post­ban installation among those participating in the smoking cessation program (ENWHP, 2008). Two large US worksites used NRT, social sup­ port, and competition to maintain cessation. Buddy supports were used in both locations, and competition between teams was added to one. Recruitment was significantly higher in the competition group, and cessation lasted longer. The long­term quit rate was doubled in the competition group but not sta­ tistically different. Buddy ratings predicted cessation (Maheu et al., 1989). Support is also important at the organization level: Intervention sites were more likely than control sites to initi­ ate and maintain structures for institutionalizing programs, such as assigning a committee responsible for health promo­ tion programs or providing a budget for health­promoting activities. Simply expanding the cessation module to con­ trol sites did not achieve the same level of success (Sorensen et al., 1998). In a “Gear up for Health” intervention, to make up for limited social support in the mobile workplace, counselors provided truck drivers with telephone sessions to set indi­ vidual goals and work through barriers to achieve those goals (Quintiliani et al., 2010). Successful participants were more likely to rate the number and content of the calls positively. Workplace hazards are also important: Motor freight workers with workplace safety and health concerns were more likely to participate in tobacco cessation interventions (Sorensen et al., 2010). To address the finding that blue­collar workers are difficult to reach and less likely to successfully quit smoking, in an intervention with construction workers, a union meeting was used to introduce a smoking intervention trial, and union feedback during the program’s design aided investigators in developing an intervention that addressed worker needs (Okechukwu et al., 2009). In this randomized controlled trial, the use of nicotine replacement patches was promoted dur­ ing group behavior counseling sessions of 1,213 union trade workers. At one month there was a significant decrease in smoking activity between the two groups; although the dif­ ference was not statistically significant after six months, there was still a significant decrease in smoking intensity. Healthy Food Access and Choices Healthy nutrition targets, such as increasing fruit and vegetables and decreasing fatty food or calorie­dense food consumption, are common in transportation sectors. In one series of controlled interventions, transit workers’ access to physical activity and healthful eating opportunities at the worksite was low, and obese workers were significantly less physically active than less heavy workers and were more likely to report work environmental barriers to physical activ­ ity (French, Harnack, Toomey, & Hannan, 2007). Programs have used participatory organizational level initiatives such as management­employee advisory boards (Linde et al., 2012) and the involvement of unions (Lassen et al., 2011) to design worksite­specific interventions and achieve best outcomes (Sorensen et al., 2007; Sorensen, Linnan, & Hunt, 2004). A fruit and vegetable intake program in a medium­ sized blue­collar business in Seattle used employee advisory boards to address healthy eating by altering menus spe­ cific to each worksite in the intervention group (Beresford et al., 2010). An intervention in five blue­collar worksites focus using union­led changes in the food environment and healthy food access achieved moderate changes in dietary patterns among intervention sites compared to controls (Lassen et al., 2011). A large transit authority implemented a multi­level pro­ gram to promote CVD prevention and healthier behaviors (Davis et al., 2009). Among many changes, a full­time trans­

160 port employee was employed to provide health information and one­on­one consulting to almost 1,300 coworkers. The program provided weekly cafeteria discounts to partici­ pants to promote onsite healthy food purchases, and vend­ ing contracts were altered so machines contained at least 60 per cent healthier options and were more affordable than less healthy choices; a significant decrease in participants’ weight was reported (Davis et al., 2009). Altered vending machine contents in bus garages can influ­ ence food purchases in bus garages (French et al., 2010a). A 50 percent increase in healthy food options and 31 percent average price reduction was associated with a 10 to 42 per­ cent higher sales of the healthy items, with snack purchase most price­responsive. In this intervention combining food availability, activity promotion, and education, energy intake (i.e., caloric intake) decreased significantly, and fruit and veg­ etable intake increased significantly in intervention garages compared to control garages. However, changes in other out­ come targets such as weight loss were not observed (French et al., 2010b). Health risk assessments were used in a transit agency to develop individual action plans for nutrition and weight management goals (Scoggins et al., 2011). Weight loss at 1 year was significant but not sustained at five years post intervention. A larger proportion of obese participants lost five percent of BMI during the first year, compared to the national average (28.5 percent vs. 23.2 percent). The SHIFT program combines competition, computer­ based training, and motivational interviewing to improve weight loss in the trucking industry and suggested as one solution to the problem of improving health behavior in a mobile workforce (Olson, Anger, Elliot, Schmidt, & Gray, 2008). Motivational interviews provided in person and by telephone in randomized study of 595 construction workers resulted in significant decreases in snack food and significant increases in fruits and vegetables in the intervention group (Groeneveld, Proper, van der Beek, Hildebrandt, & van Mechelen, 2011). Ergonomics/Musculoskeletal Disorders A multi­component program in Germany co­sponsored by the employer and union was developed to target the cardio­ vascular and musculoskeletal health of older transit operators and to improve safety, working conditions, absenteeism, and lost time (Johanning, Landsbergis, Geissler, & Karazmann, 1996). Changes included improving the benefits and reduc­ ing mandatory work time of 145 senior workers. Subjects met twice a week for 1 year, and discussed how to avoid back injury and how to participate in physical activities that focused on the entire body, especially improving back posture. After the intervention 55.4 percent of low­back­pain sufferers reported substantial improvement and only 12.3 percent reported sub­ stantial worsening. (After comparing the intervention and control group for pre­ and post­test CVD risk, there was a reduction in risk, but a non­significant difference between the two groups.) Concerns about the high number of injuries and absentee­ ism among bus drivers led the City of Regina (2002) to imple­ ment a bus­retrofitting initiative and a physical assessment program (LaMontagne, 2002). The Transfit Physical Assess­ ment Program involved an assessment by a specialized health research center of participants’ lifestyle and health, and of their physical status in relation to the specific occupational demands of driving a bus. Individual counseling, physical and lifestyle assessments, an onsite fitness center, and other similar activities also form part of the program. A bus­retrofitting program that included the changing of seats and installation of tilt steering wheels aimed to address the ergonomic issues that are associ­ ated with back injuries. At publication, there was little evidence that the program affected health and safety indicators (except perhaps for time loss days), and the difficulty in isolating pro­ gram effects from other factors, within and outside the work­ place, was recognized (LaMontagne, 2002). Other Programs Described The largest segment of information covering health pro­ tection and promotion practices in the transportation sec­ tor, and in public transit and bus operators specifically, is available in the form of government and academic reports, case studies, and other grey literature, much of it available freely on the World Wide Web. “Programmes, initiatives and opportunities to reach drivers and SMEs in the road trans­ port sector,” reviews successful health protection and pro­ motion campaigns in Europe (European Agency for Safety and Health at Work, 2010): A back injury prevention pro­ gram in Belgium provides health assessment, education, and ergonomics corrections. The Finnish “Trim Truckers” pro­ gram includes health screening, nutritional counseling, and improving schedules to allow drivers time to rest; it has also increased morale and safety culture. In Italy, a large public transit agency combines counseling and coaching on health, exercise and stress, research on health and safety hazards, and training along with other social interventions as needed, such as housing assistance. “Delivering the message” describes 64 programs, regulations, and groups across Europe and Australia that address road transport worker health. (Euro­ pean Agency for Safety and Health at Work, 2011). The Healthy Bus campaign in Denmark was designed to establish if it was practically possible for researchers to help improve the drivers’ health conditions by intervening in a systematic fashion with bus operators and management

161 (Poulsen, Drewes, Grøn, Petersen, & Bach, 2005). Healthy Bus undertook 200 interventions among the 3,500 munici­ pal bus drivers in Copenhagen over a 6­year period using a participative action research design covering work envi­ ronmental, lifestyle, health issues, and personal concerns. It did not test which interventions were successful, for reasons explained in detail in the report. Because the problems iden­ tified were not easy to solve and because operational concerns intervened, including bus companies changing hands or going out of business during the research period, the action approach identified more problems than it was able to address (Olsen et al., 2008; Poulsen, 2004) The Affinity Health System created a wellness booklet for commercial driving agencies to distribute to their workers. The booklet described warnings signs of concerns, such as sleep apnea, nutrition, fatigue, and blood pressure, and ways for drivers to deal with these concerns (Affinity Occupational Health, 2008). A chapter in Unhealthy Work describes how Transport Workers Union Local 250A, management of the San Francisco MUNI, and health researchers collaborated to target the work environment characteristics of bus driving, in response to identified high levels of hypertension, stress, and other health problems. After an observational study designed by the groups discovered that problems areas such as scheduling, passenger load, and safety and psychosocial stress contribute to hyper­ tension, contractual and policy changes were developed to increase the role of operators in identifying and addressing work environment challenges (Antonio et al., 2009). Literature Review Summary The literature describing health promotion in transporta­ tion workplaces has focused on smoking, weight loss, nutrition, and physical activity. The evidence for success parallels the findings of the Task Force on Community Preventive Services, but does not yet provide a definitive guide to what works to improve health in bus operators and what does not. Worksite smoking bans or written smoking policies have been instituted by European transit agencies and American worksites. There is evidence that highlights the benefits of these policies, and their potential in reducing workplace smok­ ing and secondhand smoke exposure. However, there is a lack of evidence on the benefit of these worksite policy influences on transit bus operators. Social support plays a notable role in the work context of smoking behavior (Sorensen, Quintiliani, Pereira, Yang, & Stoddard, 2009). Interventions targeting food and nutrition have affected knowledge and some food choices, but the impact on biometric outcomes, long­term health, and on weight change is not well documented. Although exercise promotion and food choice interventions are widely supported in transit organizations, as described later in this report, few formal research studies address the spe­ cific work context of transit bus operators. Promoting physi­ cal activity has the potential to reduce job stress, fatigue, and musculoskeletal disorder prevalence, but the literature does not identify these concerns as primary outcome measures, nor does it explicitly discuss the conditions such as schedule con­ flict, job stress, fatigue, or musculoskeletal symptoms related to work ergonomic issues that may limit a worker’s ability to achieve desired physical activity (Groeneveld et al., 2011). The same is true for eating habits. Besides the European sources looking at a wide range of tailored workplace changes, the research does not document how health­promoting environ­ mental changes can be achieved in transit organizations. Researchers have outlined several barriers that reduce the impact of planned implementations in the transit and similar industries. In particular, the mobile work and route scheduling of transit bus operators may impede the effects of health food access interventions, and the results of onsite interventions at transit agencies that promoted physical activity are limited by long shift hours, fatigue, and work­family life conflicts. Strategies to improve planning, recruitment, and program success include union and bus operator advisory groups, indi­ vidual health circles, health assessments, union and manage­ ment collaboration, and employee directed interventions, such as employee run physical fitness classes. Union support has enabled programs to utilize worksite resources to alter the food environments and address ergonomic problems. Employee advisory boards were instituted to gain worker feedback and design interventions to work with worker needs. These boards were a part of comprehensive interventions that produced successful outcomes. At the same time, interest and values frequently differ among stakeholders and may cause conflict during the design phases of the project (Cherniack, Morse, Henning, Seidner, & Punnett, 2010). Health protection and promotion are complex goals, and the application in the transit workplace is of necessity com­ plex, multifactorial, and variable across time, transit agencies, job titles, and even location within an agency. Researchers may try to target measurable and feasible changes that are swamped by organizational and other variables. Employers are likely to institute broad changes that cannot be isolated and quanti­ fied, or else institute limited changes that do not address the range of contributors to operator health. Both of these make a systematic controlled intervention and analysis difficult. The following discussion of health protection and promotion models as applied to transit workplace may help establish a more practical context for researchers and a more robust per­ spective for transit agencies. The results from transit agencies and unions as presented in the rest of this report, along with

162 the accompanying Transit Workplace Health Protection and Promotion Guide and Planning, Evaluation, and Return on Investment Template, describe the working conditions and complicating variables and a useful approach for designing and assessing effective interventions and programs. To assist in this, the Transit WHPP Practitioner’s Guide includes a link for transit organizations to share their baseline, intervention, and program data with others. The Workplace Health Protection and Promotion Model International Perspective Improving workplace health protection and promotion is a national and world-wide goal. According to the World Health Organization (Burton, 2010), a healthy workplace is one where 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 work place • Providing opportunities for participating in the commu- nity to improve the health of workers, their families, and others As discussed above, the special concerns of the transit industry are widely recognized but not resolved (European Agency for Safety and Health at Work, 2010, 2011; Poulsen et al., 2005). US Workplace Health Protection and Promotion Suggestions Several theoretical US models support the view that an effec- tive Workplace Health Protection and Promotion (WHPP) program goes well beyond individual health concerns and health promotion targets. The SafeWell model (McLellan et al., 2012) diagram (Figure 1) illustrates how health depends on Source: (McLellan, Harden et al. 2012) Figure 1. The SafeWell model for integrated worker health.

163 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, and on the phys­ ical environment (top of triangle). This 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 condi­ tions, and is firmly set in the context of organizational and community policy. NIOSH (the National Institute for Occupational Safety and Health) and the CDC (Centers for Disease Control and Prevention) recommend a WHPP program based on the con­ cept of Total Worker Health™, a strategy integrating occu­ pational safety and health protection with health promotion to prevent worker injury and illness and to advance health and well­being. The elements of Total Worker Health™ use the resources of the workplace to improve the work environ­ ment, work organization, and individual health (Table 3). Total Worker Health™ is based on a comprehensive view of health that integrates programs, policies, and practices in an overall health and safety management system. The F­17 best­practice model laid out in this report and illustrated in the Transit WHPP Practitioner’s Guide applies the Total Worker Health™ elements, supported by the broader perspective described above, to the specific demands and real­ ities of the transit workplace. Organizational Culture and Leadership Develop a “Human-Centered Culture.” Demonstrate leadership. Engage mid-level management. Program Design Establish clear principles. Integrate relevant systems. Eliminate recognized occupational hazards. Be consistent. Promote employee participation. Tailor programs to the specific workplace and the diverse needs of workers. Consider incentives and rewards. Find and use the right tools. Adjust the program as needed. Make sure the program lasts. Ensure confidentiality. Program Implementation and Resources Be willing to start small and scale up. Provide adequate resources. Communicate strategically. Build accountability into program implementation. Program Evaluation Measure and analyze. Learn from experience. Table 3. Total Worker Health™ essential elements of effective workplace programs and policies for improving worker health and well-being.

Findings and Applications: A Profile of the Industry Background This chapter describes the current state of transit agency workplace health protection and promotion (WHPP) pro- grams, detailing the aggregate characteristics, structure, and impact of programs in locations across the US and Canada. The data is derived from the survey responses, and largely follows the format of the F-17 survey questions (Appendices C and D). Specific program information is provided in Chapter 4: Case Examples and Case Studies, and detailed practices are discussed in Chapter 5: From Industry Practice to Best Practice. The transit agency and union questions differed slightly as discussed in Chapter 1: Introduction and Research Methods. Union and agency results have been combined where pos- sible, where noted they are reported separately. In particu- lar, the union survey did not address details of budget and specific outcomes concerning the management program. Although some unions had their own programs, the survey questions focused largely on the content and structure of the agency’s programs where they represented operators. The denominator—the number of answers the value is aver- aged over—varies because not all respondents were able to answer all the questions. Of 107 respondents who answered the initial survey questions, 70 have or have had a program and were asked to describe activities or define the health promo tion culture. Active program data was provided by 15 unions and 45 agencies, for 52 different locations. Most data here addresses the 52 agencies with active programs. Because using two sets of responses for one agency would risk biasing the analysis, in the 14 active programs where responses were received from both union and agency, the agency survey provided the most detailed data and was used unless otherwise noted. Program Characteristics Demographics Responses were completed by 67 agencies across the US (52) and Canada (15), and from unions at 33 US and seven Canadian agencies representing 43 local unions and six international unions. The geographical and size distributions are shown in Figure 2, and the responses by state and province can be found in Appendix B. Not all are from transit agency target locations as the invitation was shared more widely by interested unions. The names of the transit agencies and unions will not be listed in this report, except for the case studies, as a commitment of confidentiality was provided to survey respondents to increase the survey response rate and enhance openness. The survey was sent to agency heads, who typically delegated to others in the organization. Title information was provided by 61 respondents as summarized in Table 4. Detailed titles are attached in Appendix B. They came predominantly and almost equally from operations, Human Resources, and Occupational Health and Safety. Seven were at least partly in defined wellness positions. Union responses were provided mostly by elected leaders who in smaller agencies are working transit bus opera- tors as well. The data that follows in this report suggests that operations, HR, administrative, and union respondents had access to different information and understood the purpose and function of the WHPP activities and programs differently. Bus transit was the targeted industry sector and all agency respondents ran fixed-route service. Two-thirds operated at least two modes. About one-third of responses came from small and from large agencies, and about 20% were medium-sized; data was missing for the remainder. Size was also calculated based on vehicles operated in annual maximum service (VOMS) and estimated by the reported number of transit bus operators for agencies where VOMS data is not available. Size was also reported in terms of number of transit bus operators employed. Agencies ranged from fewer than 20 to more than 5,000 opera- tors. One-third of the workplaces had fewer than 113 full-time employees and one-third had more than 600. Table 5 shows the mode and size distribution for surveyed agencies. Table 6 summarizes the bus operator demographics in responding transit agencies. On the average, at least 86 per- cent of transit bus operators work full time. The workforce is majority older (average above 40, 74 percent) and male C H A P T E R 3 164

165 (average 74 percent), but in some agencies women and younger workers are strongly represented. The workforce is diverse: The average proportion of white employees is only 53 percent, and in some agencies Latino/Hispanic workers or African American workers are the majority. However, as a quarter of respondents did not provide detailed race infor- mation, this sample may not be representative of the transit industry as a whole, since larger agencies and those with a demographically diverse employee group are more likely to have this information easily available. In five agencies 100 percent of transit bus operators were contracted, and in 60 agencies no contracted operators were reported. Characterizing location-specific practices and pro- grams in contracted agencies was not possible: In the large contracting companies such as Veolia and First Transit, some activities are corporate wide but may not make it to the loca- tion, and location activities are not always shared with the par- ent company. Some transit agencies such as Austin’s Capital Metro run their own WHPP programs though employees are employed by a contractor. The workforce is highly unionized (93.5 percent), and in most cases the union represents all tran- sit bus operators. The average years of service reported was 13.9, with a median of 11. Respondents had some trouble with this ques- tion: seven left it blank, and five entered values above 54, more likely an estimate of average age rather than service years. Thus reported tenure is not uniformly high, but aging of the work- force remains a concern in some agencies according to follow- up discussions, if not a pressing one. Health, Wellness, and Safety Concerns Chronic diseases are among the top three concerns checked off by three-quarters of the respondents, followed by musculoskeletal problems and physical activity, as shown in Table 7. The results are very similar when split between union and transit agency responses, although MSDs takes the lead among the union concerns. Only 25 percent of respondents said that conditions related to the work environment were among the top three concerns. When asked about the impact of health problems, respon- dents focused on excessive absenteeism (71 percent), health costs (69 percent), and work-related injury and illness (57 percent), as shown in Table 8. Health has an impact on operating demands, loss of work, decreased morale, and Figure 2. F-17 survey respondents: distribution. Area Number Operations 13 Human resources 12 Occupational health and safety 10 Administrative 7 Wellness/Health promotion 7 Executive 4 Benefits 3 Labor relations 1 Training 1 Union 40 Table 4. F-17 survey respondents: agency department.

166 Median Maximum Number of Transit Modes 2 6 Size Percent by ridership Percent by VOMS Tertiles by Number of Operators Large 34.8 25 <113 Medium 21.4 23 113-600 Small 30.4 31 >600 Missing 13.0 21 Mode Percent Fixed-Route Buses 100 Paratransit 60.9 Light Rail 18.8 Other 17.4 Commuter Rail 14.5 Heavy Rail 11.6 Table 5. F-17 survey respondents: distribution by mode and size. # Providing Information Average Percent Work full-time 85 86.4 Female 70 25.8 Under 40 67 24.6 Latino or Hispanic 55 12.2 White 57 53.0 African American 58 26.7 Asian 49 3.8 Native American 49 1.1 Multiple race 48 2.0 Table 6. F-17 survey respondents: bus operator demographics. Health Problem Percent Chronic diseases (hypertension, diabetes, CVD, lung disease, reflux and intestinal symptoms) 75.3 Musculoskeletal problems (back injury, tendinitis, other pain) 64.5 Achieving desired physical activity, diet, and/or tobacco use status 50.5 Wellness (such as stress and fatigue) 50.5 Work environment (accidents, work-related injuries or illnesses, assaults) 24.7 Other (colds and flu; mental illness; respiratory illnesses; neoplasms) 6.5 Table 7. F-17 survey respondents: top health problems faced by transit bus operators. However, as shown in Table 9, opinions differed on how much impact work conditions have on transit operator health and wellness. For example, unions reported a strong impact of route schedules and bathroom access, which were not considered significant problems by the WHPP staff who completed the surveys. Additional conditions and policies medical disqualification in about one-third of agencies. Respon- dents report less of an impact of health on retention or turnover. Most respondents agree that working conditions have an impact on operator health. As shown Figure 3, agency respon- dents rated most exposures lower than unions did, but acknowl- edged that all the areas listed had some or a lot of impact. Effect Percent Excessive absenteeism, sick leave, or disability 71.0 Increased health care costs for the agency 68.8 Work-related injury or illness 57.0 Operational problems/delays 35.5 Loss of employment due to disability or illness 35.5 Decreased workplace morale 35.5 Medical disqualification for operators 34.4 Turnover/retention problems 18.3 Table 8. F-17 survey respondents: how operator health affects the workplace.

167 Figure 3. Workplace conditions affect operator health (% reporting some or a lot). Agency (N=67) Unions (N=40) None (percent) Some (percent) A lot (percent) None (percent) Some (percent) A lot (percent) Hours of work 20.3 37.7 17.4 20.6 52.9 26.5 Access to food 33.3 40.6 14.5 8.3 50 41.7 Contact with riding public 20.3 55.1 14.5 14.3 42.9 42.9 Bathroom access 37.7 40.6 10.1 11.4 34.3 54.3 Route schedules 21.7 59.4 8.7 5.6 33.3 61.1 Occupational safety or health conditions 31.9 46.4 7.2 20.6 52.9 26.5 Labor/management interaction 34.8 46.4 4.3 2.8 47.2 50.0 Other policies or conditions 31.9 18.8 2.9 16.7 66.7 16.7 Table 9. F-17 survey respondents: how much impact do work conditions have? suggested as affecting bus operator health, agency costs, and availability included the sedentary nature of the work, sched- ules polices including split shifts and extra boarding, ergo- nomics, and passenger and motorist contact. Workplace Health Promotion Programs Prevalence A majority of respondents had a program in 2012—52 out of 93 distinct agencies. Almost 20 percent had never had a pro- gram and did not intend to, as shown in Table 10. The average program age in early 2012 was 8 years. Respondents included brand-new programs (1 year) and mature ones (30 years), with half lasting longer than 6 years. Eight respondents projected start dates ranging from March 2012 through 2015, and one not only started up during the F-17 research period but became active as an SME location. Unions were less likely to report active programs than were transit agency respondents. This could be because the transit agencies did not complete the survey if they did not have a program, whereas unions responded to the request for infor- mation from their international union presidents whether or not they had a program. The agency and union respondents did not always agree even at the same locations: One union was not aware that there was a program, and one did not know it had been suspended for staffing reasons. Five unions ran a separate health protection and promotion program, and 10 are planning to. Five of the nine respondents who explained why they did not have a program stated that there were no staff resources. Other responses: • Program was part of an overall attendance management strategy that was dissolved.

168 • Have done bits and pieces and now need to tie it all together and re-brand. • No participants. • Not enough employee support. Scope Of the 52 WHPP programs described by agency respon- dents and unions, 12 targeted the entire bus division, 27 the bus division along with other mode or division staff within, and 13 were part of a municipal, multi-agency, or other coor- dinated program or campaign. Only 20 agencies (38.5 percent) reported that family members participate in the program, but they do so in many ways. Agencies recognize that health improvements and habit changes are more likely if supported outside of work. Where health plans cover families, many of the related services and activities are provided to them as well as to the insured employee. Some of these examples are listed in Table 11. Agency Union (about agency) Union-Run Program Yes, active 65.2 35.9 12.5 Not yet, but plan to have in the future 7.2 5 10.0 Not currently active but plan to restart 5.8 5.1 - Had in the past but no longer active 4.3 2.6 5.0 No to all of the above 17.4 53.8 72.5 Table 10. F-17 survey respondents: percent distribution by program status. Best Practice UTU LACTMTA’s wellness program has initiated a pilot 6 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: basket 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 Employee Assistance Program (EAP) including psychologists, social workers, legal advice, 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. Eligible for wellness benefits such as gym membership and training programs. Participate 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. Table 11. F-17 survey respondents: examples of family involvement.

169 Budget Reported budgets range from $0 to $372,000. Some pro- grams support a full-time staffer or more, others just the pro- motional handouts or educational material, with everything in between. Budget information was provided by 30 agencies, but five of these reported a budget of $0. This is an area where the respondents’ titles could have a big impact on whether they have complete information to provide in the survey. In addition, some of the categories listed may be funded through operating, human resources, or benefit funds rather than through the wellness program budget. Table 12 provides a survey respondent breakdown of the median and maximum program budget for different components of a health and wellness program. Program Structure and Responsibilities Responsibility is spread widely in different agencies. Overall, Human Resources runs most programs, along with operations or safety departments in some cases as shown in Table 13. There were 22 titles listed for the person identified as responsible for workplace health promotion, distributed in HR, Wellness, Occupational Safety and Health (OSH), Benefits, Training, and Operations. Table 13, Program Responsibility and Input, dem- onstrates that the responsible person may wear more than one hat. They typically do not have a lot of time available for this work. One-third of the respondents to this question reported spending less than 14 percent of their time on health protection and promotion, two-thirds had less than 34 percent time, and six responders worked on the issue full-time. The titles included health and safety coordinator; managers of welfare, risk, com- pensation, or benefits; training instructor; and consultant. Committees support the program in 33 agencies. Human Resources has the greatest representation, serving on three out of four committees, followed by transit bus operators (51.9 percent) and line managers (42.3 percent). Programs also relied on external partners. Both agency and union respondents reported the health plan as their primary exter- nal partner for WHPP activity (73.3 percent agency, 57.1 per- cent union). Other resources and allies may be underutilized. Several programs made extensive use of local and national resources, some even participating in CDC initiatives, and 13 percent worked with universities in implementing or eval- uating their programs. Union respondents reported that their responsibilities ranged from none, through mild support, member encour- agement, and active committee involvement, to paying for or running WHPP activities and program components either independently or at the worksite. No respondents were aware of US local or state legisla- tion, requirements, or other policies (that require or encour- age WHPP programs for transit employers), although many described programs set up by their health plans or used in setting policy rates. Canadian occupational health regula- tions were cited, along with APSAM (the Quebec Joint Asso- ciation for Health and Safety at Work, Municipal Sector). Incentives for health promotion activity, reported by 70 per- cent of transit workplaces respondents, include cash prizes, health-related merchandise, health club memberships, reduc- tion in health insurance premiums or copays, and recogni- tion or time off. Figure 4 shows that among the F-17 survey responders, individual prizes were most common and that very few agencies awarded time off incentives or reduced insurance premiums. WHPP Program Environment The research team assessed the reported transit industry expe- rience for indicators of WHPP program success, specifically: • What WHPP models are in place in transit? • How did the agency or union rate the organization’s health culture and organizational strength? Category Median Maximum Total $2,250 $372,000 Staff $4,900 $175,000 Outreach (newsletters, advertising) $750 $5,000 HRAs/screenings $5,000 $120,000 Training/workshops for workers $1,000 $250,000 Participation incentives $1,500 $200,000 Workplace changes (such as exercise facilities, food access, repairs) $1,000 $60,000 Payments to outside vendors for activities or products $3,975 $233,597 Other $4,900 $175,000 Table 12. F-17 survey respondents: program budget.

170 Program Responsibility Percent Reporting Human Resources 75.0 Operations 23.1 Safety 25.0 Other 19.2 Stand Alone 19.2 Medical/Occupational Health 17.3 WHPP Committee Representation Percent Including Human Resources 77.4 Transit Bus Operators 51.9 Line Managers 42.3 Other (from other or all divisions, consultants, health care providers) 54.8 Top Managers 32.7 Safety Staff 26.9 Union Representatives 28.8 Partners Percent Reporting Health Plan 69.2 Commercial Vendors 44.2 Community Groups (for example, Weight Watchers™, American Cancer Society) 42.3 City, State, or Federal Health Departments 19.2 Other (CDC/HHS, 3rd-party fund administrators, health care facilities) 17.3 University or Other Academic Center 13.5 Workers Compensation 17.3 Table 13. F-17 survey respondents: program responsibility and input. Figure 4. F-17 survey respondents: incentive use with WHPP programs.

171 • How competent were the programs? • How did the transit agencies rate their program impact? • What specific practices did they report? • How do these programs and practices compare to recog- nized standards of excellence in WHPP? • How did the transit agencies evaluate their programs, includ- ing return on investment or other economic assessment? What WHPP Models Are in Place in Transit Agencies? Based on the surveys and follow-up discussions, existing transit agency program health promotion models were catego- rized as Traditional (health care/disease prevention with focus on individual risks and solutions), Health and Wellness (health care/disease prevention, with work organizational support for wellness and health such as stress reduction or group sports activities), and Integrated (health care/disease prevention, work organizational support, and occupational and work envi- ronment targets such as route schedules, safety). As expected, the traditional disease-focused programs were most common in responding transit agencies (40 percent), followed by the more extensive health and wellness models (33 percent), and then the integrated work-life programs (27 percent). In follow-up discussions, many respondents described their intention or desire to address work demands such as bathroom access, occupational health and safety, and work/ family conflicts. These were planned to better integrate work- place health protection and individual health promotion. Survey respondents noted structural impediments to effec- tively integrating programs. Because of their placement in the organization, typically within human resources, and their lack of experience as transit employees, program staff may have limited status and impact on areas beyond health promotion. WHPP programs in organizations with effective safety com- mittees and more integrated communication were often able to surmount these barriers more effectively, by placing health in the context of occupation and work exposures and, criti- cally, by adapting the scheduling and content of activities to suit the transit work environment. How Did the Agency or Union Rate the Organization’s Health Culture and Organizational Strength? The survey asked for ratings of WHPP programs and health culture on the five organizational support and eight program strength characteristics listed in Table 14. These characteristics are based on the constructs “Willingness” and “Management” validated in the Worksite Health Promotion Capacity Instru- ment (Jung et al., 2010), with additional concepts from the National Worksite Health Promotion Survey (Linnan et al., 2008), and the management and union support questions from the TCRP Synthesis 52 questionnaire (Davis, 2004). Respondents rated their organizations on each element from strongly disagree (coded as -3) to strongly agree (3). Figure 5 shows the average rating for the organizational sup- port, program strength, and composite health culture score. Organizational Support Upper management has made employee health promotion a top priority Union leadership supports and participates in the workplace health promotion program (unionized workplaces only) Employee health promotion has been integrated with other operational and administrative policies and procedures There is a person identified who has primary responsibility for the program Others in the organization take active responsibility for the program Program Strength An effective committee leads or supports the program The program links with other organizational areas, for example, occupational health and safety, benefits Workplace data is used to determine program direction The program has a long-range (3-5 year) strategic plan The program responds to changing needs Management allocates adequate resources for the program (budget, space, etc.) Managers actively promote participation in health promotion activities Transit bus operators are actively involved in program development and implementation Table 14. F-17 survey respondents: health protection and promotion culture and strength.

172 Respondents were on the whole positive when rating support for their programs and the program strength, although not strongly overall (1 = somewhat agree). Confidence in the pro- gram strength appeared to increase with size. Transit agencies rate the program and the support it receives more positively than the unions do. The average union rating for overall organizational support is slightly positive, and the total rating is slightly negative, compared to positive average rat- ings from transit agencies (0.6–0.7, with 1 = somewhat agree). In addition to the lower level of confidence in program charac- teristics compared to the agency, as detailed in Figure 6, there is an important difference in perspective: union respondents feel that they do support and participate in WHPP, but very slightly disagree on average that WHPP is a priority for top manage- ment; the agency representatives report that top management supported their programs but neither agreed nor disagreed that the union supported or participated. Both acknowledge that transit bus operators are not actively involved in program Figure 5. F-17 survey: rating the WHPP organizational support and program strength. Figure 6. F-17 survey respondents: average rating of organizational support and program strength by transit agencies and unions.

173 development. In eight cases where ratings were supplied by both agency and union, the agency respondent rated the same programs 2–3 points higher than the union respondent did for available resources, links to other areas, and use of data, and about one point higher on everything else (data not shown). In some cases the responses were 6 points apart on the 7-point scale when rating the same program. On average the unions reported supporting the program more than management acknowledged they did. This divergence is not uncommon in workplace culture assessment research. While instruments have been shown to measure similar constructs, when filled out by labor and man- agement the average scores differ, with labor rating the cul- ture as less positive than management (Sawhney, Cigularov, & Kines, 2013). The finding that both labor and management felt they supported the aims and intentions of the WHPP but each undervalued the commitment of the other party remained a consistent theme in follow-up interviews. This difference rep- resents a key target for improvement across the industry. Bus operator health, safety, and wellness are a recognized priority for all parties, but an acceptable model for cooperation has not yet been established in many locations. Among the most suc- cessful transit agencies investigated in the case studies, trust, respect, and commitment were expressed from all parties. How Competent Were Organizations? Six core characteristics were identified for targeting com- petent programs for further investigation, case descriptions, and follow-up. Competent programs were expected to be based on a programmatic approach rather than one or a few isolated activities: recruit involvement throughout the organization, address retention and other operational needs, collect evaluation data, collect health outcomes data, and cal- culate or quantitatively estimate a past or projected return on investment. Table 15 shows the distribution of each com- petency among the 43 transit agencies that provided enough supporting information in the survey or via follow-up contacts to rate program types and activities. Of these, 25 (58.1 percent) demonstrated four or more of the competencies and were interviewed as potential cases. Almost all programs (88.4 percent) were based on a pro- grammatic approach rather than one or a few isolated activ- ities, and about half (48.8 percent) recruited involvement throughout the organization. Addressing retention and other operational needs in some way was reported by 58.1 percent. Agency survey respondents tended to agree that the WHPP program was well integrated with operational administra- tive policies and procedures (54.8 percent) and areas such as safety or benefits (66.1 percent). The union survey respon- dents seemed to disagree that the WHPP program was well integrated (26.4 percent and 31.6 percent). Many respon- dents felt that information and decision making often took place in silos of influence, limiting effectiveness. In follow- up discussions it was clear that WHPP program activity in fact frequently overlapped with worker health protection and related concerns such as ergonomics. Following the survey process, many respondents spoke about planning to integrate their activities to improve effectiveness. Three out of four transit agencies with programs collected some evaluation data, half collected health outcomes data, but only a quarter calculated or estimated a return on invest- ment. The more integrated programs also tended to report more of the core competencies. There was however a lot of overlap and at least one agency demonstrated all competen- cies but included only traditional model targets and structure. Some research suggests that a successful program needs to provide a range of activities and resources to employees, and that a wider range is more likely in larger organizations (LaMontagne et al., 2004). In the F-17 survey, competen- cies varied by organization size, but not directly, as shown in Table 16. Smaller transit agencies were less likely to report Competency Total Percent of Integrated (n=11) Percent of Health and Wellness (n=13) Percent of Traditional (n=19) Based on a programmatic approach rather than one or a few isolated activities 88.4 100.0 92.3 78.9 Recruit involvement throughout the organization 48.8 72.7 46.2 36.8 Address retention and other operational needs 58.1 100.0 84.6 15.8 Collect evaluation data 79.1 90.9 76.9 73.7 Collect health outcomes data 55.8 63.6 53.8 52.6 Calculate or quantitatively estimate a past or projected return on investment 30.2 36.4 30.8 26.3 Table 15. F-17 survey respondents: distribution of program competencies.

174 involvement across the organization. Medium-sized transit agencies seemed stronger in all areas than the larger or smaller respondents. In particular, they are more confident in their abil- ity to recruit involvement across the organization, and more likely to carry out evaluation. It is possible that evaluation in larger organizations is being done by other departments that the WHPP staff person is not aware of. In case example follow- up and interview discussions, it became clear that while ade- quate resources are very important to program success, those resources can be identified in small, medium, and large agencies if communication and access across disciplines is possible. There was some regional variation in competencies as shown in Table 17. Transit agencies in Canada were more likely to report targeting retention and operations, and to enlist wide participa- tion (although agencies in the Northeast were also strong in this area). This may be related to requirements for joint labor- management safety committees that are more common in Canada. They were less likely to report evaluation activities. How Did the Transit Agencies Rate Their Programs’ Impact? The 52 active WHPP programs reported by survey respon- dents were set up predominantly to lower work-related injury or illness rates (82.7 percent), reduce health care costs (78.8 per- cent), and improve availability (69.2 percent), as shown in Table 18. But less than a quarter could confidently report that the programs had an impact on those original targets. Those initially concerned with creating a safer work environment and with morale were most successful at hitting their original tar- gets: 34.3 percent of the number targeting morale achieved some impact, as did 37 percent who hoped to create a safer work environment. Improved retention was not a leading target for WHPP programs, reported by only 22 transit agencies and achieved by five of those, only 9.6 percent of all active programs. Some transit agencies reported successes in areas that they did not intentionally address. For example, transit agencies with only traditional health-specific targets noted improvements in workplace safety. This pattern of response supports the Total Worker Health™ model (Centers for Disease Control and Pre- vention, 2013), suggesting that activities and policies can have an impact beyond their target areas. As one researcher has put it, “The often-ignored well-being risks such as work-related and financial health risks provided incremental explanation of longitudinal productivity variations beyond traditional measures of health-related risks.” (Shi et al., 2013) The success claimed in apparently untargeted areas also indicates that pro- gram staff may not always distinguish observed changes from program impacts, and may not have the resources to effectively evaluate the effect of the program activities. Some respondents hesitated to say that their activities were responsible for improvement they had observed. Even program staff with extensive programs noted that matching practice to outcome is difficult. This is in part because they run the pro- gram in the short term whereas health change takes longer. Most critically, many variables can change at once, including working conditions and who is employed at any given time, especially in organizations that are improving continuously. Observed outcomes may be secular trends in the population, affected by external or unintended factors, or coincidental changes. Programmatic Recruit involvement Targets Retention/ Operations Enlist Wide Participation Evaluate Calculate ROI Large 80.0 45.0 60.0 80.0 40.0 20.0 Medium 100.0 81.8 72.7 81.8 81.8 45.5 Small 91.7 25.0 41.7 58.3 41.7 16.7 Table 16. F-17 survey respondents: percent with competencies by organization size. Programmatic Recruit Involvement Targets Retention/ Operations Enlist Wide Participation Evaluate Calculate ROI Canada 75.0 58.3 91.7 83.3 33.3 33.3 Midwest 90.0 40.0 40.0 60.0 40.0 20.0 Northeast 100.0 42.9 42.9 85.7 71.4 28.6 South 85.7 28.6 42.9 71.4 57.1 28.6 West 100.0 71.4 57.1 71.4 71.4 14.3 Table 17. F-17 survey respondents: percent with competencies by region.

175 WHPP and Workplace Policy Fewer than half of respondents include organizational or policy changes as a direct role for their WHPP programs. However, related policies such as return to work accommo- dations, assault or customer conflict prevention programs, workplace health and safety inspections, and other workplace health, wellness, and safety programs were each reported by more than half the respondents. Respondents reported that 30 to 60 percent of those programs had an impact (Table 19). Table 20 lists specific policies that respondents reported had an impact on workplace health protection and promotion. Target Original Purpose (percent reporting) Impact (percent reporting) Impact/Original Purpose (percent succeeding) Lowered work-related injury or illness rates 82.7 23.1 27.9 Reduced health care costs 78.8 19.2 24.4 Improved availability/lessened absenteeism 69.2 13.5 19.4 Improved morale 67.3 23.1 34.3 Reduced workers’ comp costs 65.4 17.3 26.5 Improved health measures 63.5 19.2 30.3 Safer work environment 51.9 19.2 37.0 Improved retention 42.3 9.6 22.7 Table 18. F-17 survey respondents: original WHPP program purpose and impact to date. Policy Agency (N=45) Union (N=15) Have Policy Policy Has Impact Have Policy Policy Has Impact Return to work accommodations 66.7 56.7 57.1 37.5 Assault or customer conflict prevention program 57.8 30.8 35.7 19.9 Workplace health and safety inspections 57.8 38.5 28.6 50.0 Other workplace health, wellness, and safety programs 68.9 57.1 35.7 19.9 Bathroom access policy 42.2 15.8 21.4 33.2 Healthy food availability 35.6 12.5 14.3 49.7 Policies to prevent or reduce stress at work (scheduling, customer encounters, restroom access) 33.3 26.7 7.1 0 Policies to help balance work life and family policies (family leave, phone calls) 31.1 28.6 0 0 Other policies or programs 13.3 66.7 7.1 0 Route and shift schedule policies to reduce health impact or stress 11.1 0 0 0 Incident/near-miss reporting system 0 0 21.4 0 Table 19. F-17 survey respondents: policy in areas related to operators’ health.

176 to influence other areas beyond health promotion. The larg- est numbers report an influence on safety rules (38.5 percent) and on training (36.5 percent) as shown in Table 21. When asked, “What could be done to improve your work- place health promotion program?” the largest number cite resources, as shown in Table 22. This includes funding, staff, and space. Respondents did offer practical ways to increase organizational support and integration, and a long list of ideas and plans for making their programs more effective, as detailed in Appendix B. Although only a few referred to the need for transit-specific resources and programs in the survey, this was a dominant theme in follow-up discussions. Chapter 4: Case Examples and Case Studies introduces some of the individual agencies that are working to address their employee health protection and promotion needs, and the next chapter describes their practical approaches. Individual Health Wellness program Tobacco free policies Counseling program for all employees Health/wellness/fitness program benefit for all employees Access to fitness facilities on site Work Organization Increased service levels reducing crushload issues Windows of time that operators work within, extra board, Federal time regulations keep drivers from working excessive hours Attendance support program (both positive and negative) Attendance and disability management Occupational and Environmental Increased access to washroom facilities Work safe policies including slip resistant footwear Mobile device policy—restricting positive, no music to two days off in a row reduce stress negative Table 20. F-17 survey respondents: examples of policy changes that affect operator health. Area of Influence Percent of Responses Safety rules 38.5 Training 36.5 Individual work assignment 23.1 Hiring 23.1 Vendor selection 21.2 Scheduling 13.5 Bus procurement 11.5 Other areas 1.9 Table 21. F-17 survey respondents: where do WHPP staff have influence? Category Count Resources 23 Support/integration 13 Participation 12 Assessment 9 Structure 8 Policies 3 Transit-specific information and practice 3 Healthy environment 1 Table 22. F-17 survey respondents: what could improve the WHPP program? Safety policies had a direct effect—for example, providing slip resistant footwear reduced slips and falls and seemed to increase morale and trust. Some polices had positive and negative effects on health. Attendance policies in particular were reported to both improve attendance and decrease the rates of illness, but they also were seen to increase stress and conflict. Similarly, a manager reported that a mobile device policy had a positive impact on safety but it also ruled out the use of music as a stress-reduction measure for drivers. Overlap is clear in some of the categories defined by the survey—for example, nutrition could be an example of edu- cation, counseling, or polices that support a healthy environ- ment. Further probing shows that most nutrition activities are part of education and health fairs, but some transit agencies address the problem more programmatically with vendor contracts and cost subsidies. Although healthy food knowl- edge may be easier to achieve, addressing food availability is a clear priority for labor and management that has not yet been fully realized. In integrated WHPP, the program can provide input and support to other areas including operations, human resources, and occupational safety and health. In this sample of transit agencies with apparently successful WHPP programs, about one-third of respondents or less believe they have the capacity

177 Case Examples and Case Studies Background Before selecting the case study locations, the F-17 research team developed a catalog of workplace health promotion programs using the survey responses and follow-up inter- views. This catalog provided a snapshot of agency and union survey responses, summarizing the agency’s programs and identifying any perspective barriers to program implementa- tion. This catalog is organized by agency size as defined by the VOMS. Agency names have been withheld because the survey cover letter stated that all information gathered in this survey will remain confidential and only grouped data will be shared or published. The case example reports were based on survey data and ini- tial telephone follow-up interviews. Not all sources responded to all questions, so the information presented below may vary in the details provided. Analysis of the case example catalog descriptions, in-depth interview questions, quantitative data, and case study criteria identified five locations for in-depth case studies. The agencies selected illustrate successful responses to the demands and problems that agencies encounter in setting up their programs. Their stories frame the relevant sections of the Practitioner’s Guide. Two final summary case discussions cover the combined examples of small agency respondents and the particular issues facing multi-agency programs offering health and wellness programs through a city, state, or county government entity. Learning from Industry Practice: Case Studies • Getting Started—Preparing the organization and making the commitment—United Transportation Union (UTU) and Los Angeles County Metropolitan Transit Authority (LACMTA)—Los Angeles, CA. • Building the Workplace Health Protection and Promotion Team—Dallas Area Rapid Transit (DART), Dallas, TX. • Setting Targets in Transit Health Protection and Promotion— Edmonton Transit System (ETS), Edmonton, AB. • Integrating an Effective Transit Workplace Health Protection and Promotion Program—Orange County Transportation Authority (OCTA), Orange County, CA • Evaluation, Return on Investment, and Ongoing Improve- ment—Capital Metro, Austin, TX • Maintaining Effectiveness with Growth—United Transpor- tation Union (UTU) and Los Angeles County Metropolitan Transit Authority (LACMTA)—Los Angeles, CA. • Lessons from small agency programs. • Lessons from multi-agency programs. F-17 Case Example Catalog Small Agency Examples Agency 1 (Small): Agency 1 is a metropolitan transportation authority that operates various modes of public transportation—bus (local and commuter), light rail, paratransit, and vanpool in the western US. They have an integrated health and wellness pro- gram that does not involve family member participation. A few years back, they did a study to help determine what the health risks were to their employee population. Based on that study, they have been focusing on targeting smoking cessation, physical exercise, stress reduction, and weight management. Two years ago, they purchased services to have an onsite well- ness coordinator (who is actually a personal trainer) to work with transit bus operators on their health and wellness on a more consistent and flexible basis. Since the wellness coordi- nator is contracted, participation has increased due to fewer concerns about confidentiality and the flexibility of schedule. Agency 1 considers it important to have support from executive management. They are thankful that upper man- agement believes in the program and maintains a consistent budget for the program. They believe a barrier to success in their program is the absence of a fitness center at the actual location where employees clock in and out for work (they have fitness locations at other areas). They believe this barrier C H A P T E R 4

178 makes it easier for employees to leave work and not go to the fitness center locations. Agency 2 (Small): Agency 2 is a metropolitan transportation authority that operates bus service and paratransit service in the midwest- ern US. They have an active 3-year traditional health and wellness program that covers family members by offering smoking cessation, discounts to fitness facilities, and coun- seling services to employee family members. Their “Ask a Nurse” program provides blood checks, stroke assessments, and answers to health-related questions for transit employees. Coordination with the urgent care facility and nurses helps them find health-related targets like sugar consumption, sun- screen, etc. They are currently in the process of setting up a wellness mobile unit that will provide biometric screen- ing, health risk assessments, blood pressure, body fat per- cent, BMI, lipid panel, glucose, and telephone follow-up with employees. Agency 2 considers it important to provide information to employees. They believe the program could be improved by better employee participation. A major barrier to their pro- gram success is designing a program around the operator’s schedule. They are currently in the process of trying out some new schedule techniques to try to increase employee partici- pation in wellness events. Agency 3 (Small): Agency 3 is a public transportation provider in the north- eastern US. They have a wellness program that is run by the health insurance provider through a pooled insurance plan. The insurance premium can be lowered when employee par- ticipation goals are achieved for wellness activities such as gym membership, aerobics classes, cardio workout, nutrition- ist visits, and smoking cessation support groups. As a result of employees meeting the participation goals, their health pre- mium is reduced by two percent for the upcoming year. The agency would like to play a more active role in both promotion and participation in the program. Currently, the program exists only because the insurer offers it at no addi- tional cost. The biggest barrier for program success is the lack of budget for employee health and wellness. Agency 4 (Small): Agency 4 is a nonprofit transportation provider that oper- ates various modes of public transit bus, bus rapid transit, paratransit, carpool, and vanpool in the southern US. They have a health and wellness program that is a part of their health insurance. Meetings with the health insurance com- pany are used to target wellness activities based on health care claims and the types of ailments that the insurance company is seeing operators report. This year they started a program in which they will pay for employees to go to a gym facil- ity and have a one-time consultation with a nutritionist who will help them set up a healthy diet and exercise plan. Even though their program is fairly new, they calculate their return on investment by comparing the price of their health care plan to the cost of the health care claims cost. Agency 4 considers it important for the program to have a combination of activities to offer employees that they can actually benefit from, while re-evaluating every year to deter- mine participation trends. A barrier to their program success is low employee participation, even though they are trying to look at a combination of methods to help employees. Agency 5 (Small): Agency 5 is a non-union agency that operates campus bus routes in the southern US. While they do not have a formal health and wellness program, they receive wellness weekly newsletters and educational posters from a local medical center. Agency 5 believes that their current model works in their environment because employees are always interested in the educational posters. However, there is no way for them to measure if employees are actually performing more health and wellness activities. Medium Agency Examples Agency 6 (Medium): Agency 6 is responsible for the operation of a public transit system in Canada. The program has modest ambitions that are being met through slow growth. Health and wellness tar- gets are addressed from a range of different departments and programs. The 4-year-old wellness program focuses on tradi- tional lifestyle choices and targets such as exercise and weight loss challenges, nutrition, and health education. There are some activities, such as healthy barbecues, that allow family involvement but they have not been well attended. The union also provides services in areas including counseling, educa- tion, health and safety, and workforce development. Integration is informal, as wellness activity is facilitated by HR staff who share information across programs such as atten- dance, disability management, and scheduling. The Wellness Committee is a subcommittee of Safety and Health. For exam- ple, HR is involved in the joint scheduling planning meetings, where the impact of schedule demands and over crowding on operator health is acknowledged. There is an attempt to include recovery time in scheduling, although this remains difficult as resources shrink. Integration is also enhanced because the union is active in the related areas of health, safety, and operations. The agency continues to address many of the organizational and environmental issues that contrib- ute to operator health challenges. External partners include the health plan and the workers compensation insurer.

179 Retention is not a concern with less than 1 percent turnover per year. The agency tries to hire more experienced people; although this does mean an older and possibly less healthy workforce. They are also more able to adapt to some of the work demands. The wellness program is planned to target and take advantage of the issues related to the older workforce. The committee brainstorms and develops ideas with input from all members. Targets are selected in part through trial and error—for example an early health risk assessment was not well received and so was discontinued, and a family swimming event did not succeed partly because many operators were not comfortable with their physical status in a mixed gender envi- ronment. The Union supports the activities but has a different perspective on priorities, highlighting such barriers to partici- pation as the circular route system, lack of terminal locations, and other schedule issues that make exercising at or near work difficult for many. Health-related environmental conditions such as access to bathrooms have been addressed sporadically but not directly via the wellness program. Location conditions including operator rooms and access to exercise equipment are not yet optimal. The agency has an ergonomist who visits locations weekly. Starting with high-injury areas, the project has continued to analyze equipment issues such as seats and brakes, as steer- ing demands as well as maintenance challenges. It responds to issues raised by operators and maintainers. Although not officially part of the wellness program, there is a direct impact on health and comfort as well as morale. Participation is low (about 15 percent for any activity) but increasing. A recent walk challenge has been popular, as are team competitions. Specific health targets and activities may be tailored to locations, with the support of the depot chairs; additional informal champions are very important to the pro- gram’s success. Budget problems limit the ability to improve recognized problems such as schedule demands, and make expanding the program difficult. The agency is using a wide range of data to attempt to develop and improve the program. Insight into the failures of some activities is clearly important to developing participation and using the available resources to address health needs more reliably. Agency 7 (Medium): Agency 7 provides bus transportation within the north- eastern US. Personal financial education is a major target of the wellness program, including a financial wellness library, mandatory trainings from a retirement plan specialist, one- on-one consultations with a financial planner, and manda- tory training on personal finance management. The agency has received a national recognition award for this. Other activities include health fairs with alternative health resources, walking and weight challenges, mandatory and voluntary training and counseling on health, wellness and ergonomics, mandatory training on diabetes prevention with voluntary diabetes screenings, and stress education and screening from their insurance provider. Because participation in many of the components is mandatory, the rate is 100 percent; par- ticipation in voluntary activities is reported at 20–30 percent. Family members can participate in financial health activities and annual wellness events. Agency 7 participates in a brokered municipal health care insurance pool, and has seen its health costs trending down since 2011, recently achieving a quarterly surplus. While this is not unequivocally attributable to the program activities, there is a consistent and satisfactory improvement. Notably, the program uses a wide variety of data sources to plan and assess program components, including a financial stress sur- vey instrument, data from the insurance pool, and internal indicators. The wellness program manager cites significant support at the top management level as a motivator for the program, as well as the involvement of passionate champions at all levels. Major remaining barriers include ongoing contract negotia- tions and limited program funding. Although no input from the local union was received, other union sources suggested that support for the program may not be as strong as reported by management. An initiative to require operators to submit to CDL physicals despite not being legally required has led to extended labor-management conflict, and the last contract has expired without an agreement. Agency 8 (Medium): Agency 8 operates a state transportation system in the northeastern US. They have a 20 year old program consist- ing of health fairs in each division and monthly nurse visits to each location to perform voluntary blood pressure and weight monitoring. Fully equipped fitness facilities are pro- vided at each division and are used by about 20 percent of the employees. Through the employee assistance program (EAP), the company also makes resources available to employees whose physical and mental health may be affected by personal or family problems. Two years ago, a more formal health and wellness program was implemented. A fitness consultant vis- ited each division and held educational sessions with opera- tors, mechanics, and administrative employees, focusing on a special topic each week, such as diabetes, back pain, and weight management. The consultant offered advice on lifestyle choices and recommended exercise options. After 7 months of experi- mentation, the program was discontinued due to system-wide budget cuts. Even though the program was not in place for long enough to produce measurable results, based on anecdotal evi- dence, it has had some impact on raising health and wellness awareness among participating employees. There are employee safety and health committees in each division as required by the agency’s self-insured status for worker’s compensation.

180 The agency would like to make health and fitness less vol- untary for employees (e.g., require smokers to quit, require obese employees to enter a weight loss program, and other interventions to require healthy lifestyles), and to work with the union on putting in place incentives for participation and disincentives for unhealthy lifestyle. Budget cuts have been a barrier for broader program success—when service routes are cut, it becomes difficult to maintain a comprehensive wellness program even though the cost is fairly low. Agency 9 (Medium): Agency 9 is a metropolitan transportation authority that operates various modes of public transit bus, bus rapid tran- sit, paratransit, and vanpool in the midwest US. They have an active 10-year traditional health and wellness program that does not involve family members. Their recent focus has been on weight reduction and healthy eating. These topics were targeted after a meeting with their healthcare provider where they did an overview of employee utilization of their program. Some of the activities that their health and wellness program provide are the fresh fruit and vegetable market and the walking at work program. The fresh fruit and vegetable market is a vendor who comes out to the worksite and pro- vides fresh fruits and vegetables for employees to purchase. The walking at work program is a program that they had this year where they put together teams to compete in a walking challenge; there were 300 participants and all participants received a T-shirt. The agency is also in the process of putting together a bike loan program so that employees can ride bikes during their lunch times. Agency 9 considers it important for the program to be employee-centered, include incentives, be educational, and have some variety. They believe their program could be improved by wellness incentives that impact monthly premiums, an onsite medical clinic, and physical hiring requirements. A barrier to their program success is developing programs where every- one can benefit without it being too costly (for individuals that are not a part of the health insurance plan, the agency has to pay for their participation in any health and wellness activity). Large Agency Examples Agency 10 (Large): Agency 10 is a public transport bus operator in Canada. The agency has a 4-year old, comprehensive corporate healthy workplace program that is open to all staff, including transit employees. It includes an EAP, weight loss program, nutrition, targeted campaigns and challenges such as heart awareness and walking challenges. These activities are supplemented by health resources on the corporate healthy workplace website. A full-time healthy workplace specialist in the city’s human resources coordinates with the transportation department on corporate-wide and department-specific programs, includ- ing a designated fitness center at the transit center. One of the innovative programs the City initiated is peer support for mental health since 2004. The program is well utilized. As discovered shortly after the beginning of the program, frontline operator involvement in wellness and health com- mittees was a challenge, given the schedules of the operators. Operator feedback is collected through a comment box in the fitness room and satisfaction forms following activities. Nutrition and physical activities are the top bus operator concerns, according to management respondents. A health assessment survey is planned for the near future. The agency would like to expand their program to involve families more. The biggest challenge to the wellness program is the nature of the bus operator work and schedules. Pro- gram planners make a conscious effort to schedule activities to maximize bus operator participation. Agency 11 (Large): Agency 11 provides public bus transportation in the mid- west US. This program is based on a strategic partnership between the vendors and the wellness team employees. They also send out surveys to employees to help determine what areas they should target. They include family members in their program by allowing them to complete health risk assess- ments, work with a health coach, and complete a 6-week online learning module. Their most utilized wellness com- ponent is their walking program where they offer employee challenges to see who can walk the farthest using a pedometer for tracking distance walked. Agency 11 considers employee participation the most important factor. All employees received mailings, and almost half have participated in exercise or weight loss challenges, but only 6 percent have completed an HRA. Their program could be improved by additional internal resources, a well- ness liaison at each location, and more union commitment. A major disadvantage to their program is that they are not able to provide a big enough incentive for employees. Agency 12 (Large): Agency 12 is a metropolitan transportation authority that operates various forms of public transit—bus, electric trolley bus, hybrid bus, light rail, and streetcars—in the western US. The health and wellness program is administered through the county government and is not specifically focused on transit operators. As county employees, transit employees are eligible to participate in the program, but there is no budget dedicated to transit. Program administration is centralized through the county HR department. The online program is designed to lower employees’ out-of-pocket health care

181 expenses by having them complete individual action plans and track their progress online. There are 3 levels of benefit statuses, with “Gold” status providing the lowest out-of-pocket employee expense. In addition to their county-wide program, the transit divi- sion also provides scheduled comfort stops within their tran- sit schedules so that operators have an opportunity to use the restroom while driving on their route. There is an extensive ergonomics program involving transit bus operators and the local union is extensively involved in ergonomics and health and safety issues including equipment assessment and design. Agency 12 thinks it is important that a program has a vari- ety in choices and incentives. The union representative thinks it is important that a program is voluntary and rewards par- ticipation instead of financially punishing those employees who choose not to participate. According to management, the major barrier to program success is that the program is pri- marily online. Management believes that it is more difficult for transit bus operators to become involved because they are out on the routes all day. The union feels that the major barriers to program suc- cess are the lack of respect for the program and the fear of personal information not remaining confidential. According to a union representative, most members feel that the pro- gram is designed for office workers and not the blue-collar workforce. In an attempt to prove this point, the union has hired consultants to get access to the wellness program data, and has shown that while 90 percent of County employees are Gold status, only 56 percent of union members have been able to achieve that. Agency 13 (Large): Agency 13 is a metropolitan transportation authority that operates various forms of public transit—bus, light rail, and commuter rail in the midwest US. They engage in a wide range of health protection and promotion activities where health targets are based on health insurance utilization and yearly health assessments. The most innovative thing that management believes they have done is promote and support an employee who put together a bike team for diabetes called “Bike for the Cure.” This program has been in operation for 3 years, with full agency support, and “participation is huge.” They believe that overall the entire health and wellness pro- gram is a morale booster if nothing else. The union believes that management is constantly making improvements to the health and wellness issue. They believe that their restroom policy and employee education on the restroom policy is the most innovative thing that the agency is doing. The agency contracts with businesses along bus routes to allow employees to use their restrooms, if needed, while driving their route. They also ensure that during train- ing employees are trained on the importance of using the restroom when necessary and shown the location of rest- rooms that can be used along the routes. Agency 13’s management stated that top-down bottom-up support is important. Upper management should participate in and support the program and grassroots activities. The union believes that it is important that the agency educate transit bus operators on the reality of bus operator assaults, be honest about the verbal abuse they may encounter, and teach them how to deal with these kinds of situations. The agency management believes that the major barrier to program success is the fact that employees are not getting paid to participate in the program. The union agrees that the major barrier to program success is the fact that the agency does not offer incentives for participation in the program. Agency 14 (Large): Agency 14 is a metropolitan transportation authority that operates various forms of public transit—bus, subway and elevated rail, commuter rail, light rail, and electric trolley bus in the northeastern US. Sleep apnea awareness has been an area of focus at Agency 14. A current program allows tran- sit bus operators who think they have sleep apnea to see a sleep specialist and copays/deductibles are waived. However, because there are no tangible incentives and the potential danger of being medically disqualified if diagnosed, only 100 of the 250 available opportunities have been taken. Agency 14 is also implementing a pilot program on dia- betes education through the health plan. The only incentive plan related to the pilot program involved $25 gift cards for each access and $200 if employees complete the entire pro- gram, paid by the insurance company. The diabetes program is very new; there is no data yet on health outcomes. Partici- pation is high, at more than 800 employees, possibly because of the incentives. Agency 14’s management respondent considers it impor- tant to implement program incentives, build trust, and raise awareness that people are responsible for their own health. The union representative would like to have a truly joint pro- gram with union involvement, built on a trusting relationship between the two parties. It is also deemed as key to program success not to impose any negative consequences on partici- pating workers, such as medical disqualification. According to agency management, the major barrier to their program success is budget. They do not have a dedicated wellness budget, which limits the amount of staff resources and variety of activities offered. As a result, incentives may not always be provided and participation tends to be low. The union sees trust and confidentiality as the issue holding transit bus operators back from participating more actively and the union from promoting the company program. Health initiatives were discussed at joint meetings but the relation- ship between the agency and the union has prevented the union

182 from becoming an equal partner in the design and imple- mentation of the health and wellness initiatives. Because of lack of trust and confidentiality concerns, the potential for medical disqualification becomes a “fear factor” for opera- tors who might otherwise participate in the sleep apnea program. Agency 15 (Large): Agency 15 provides public bus service in Canada. The union’s focus is on the health and safety of operators while working, including assaults, access to bathrooms and good food, and schedule stress. These issues are addressed in joint health and safety committee meetings, but in their perspective the wellness activities they are aware of (yoga classes, some attempt at gym access) have little relevance because resources are not made available to match the schedule demands of tran- sit bus operators. Health screenings seem to restrict transit bus operators from working rather than support them in remain- ing or becoming healthy. In this environment, it will be important to enlist transit bus operators and their representatives to develop activities and the program that is supported and effective. Case Studies Dallas Area Rapid Transit: A Case Study in Team Building A. Background Dallas Area Rapid Transit (DART) is a metropolitan trans- portation authority that operates bus, light rail, commuter rail, and paratransit in Dallas, TX, and its 12 surrounding cities. DART began operation in 1983. DART operates 120 routes with 37.2 million passengers annually. They have a vehicle fleet of 612 vehicles, with 15 transit centers, and 12,500 bus stops. DART has approximately 3,100 employees, including 1,641 fixed-route transit bus operators. DART mechanics and transit operators are represented by Amalgamated Transit Union (ATU) Local 1338. Sources: Wellness Specialist Local Union President Union Wellness Committee Members B. Case Focus: Team Building for Wellness DART is a good example of how an agency can make changes within a program to bring people together and build a team. Starting with building a wellness committee that is represen- tative of the program population, they have created a team focused on increasing program participation and implement- ing effective program components. Committee members are active in the program and are consistently looking for ways to improve the program every year. At DART, the wellness specialist is responsible for imple- menting the wellness program for all of the employees (transit and non-transit). Prior to the arrival of the current wellness specialist, the wellness committee had been composed of approximately 40 people with only 4 men, mainly the execu- tive assistants to the different departments. The majority of the committee did not participate in the wellness program. Despite resistance from veteran committee members, the old committee was disbanded and recreated to be more represen- tative of the DART population. Today, the wellness committee consists of representatives recruited from each department (with at least 3 or 4 transit operators), and includes a majority of men, a more ethnically diverse population, more frontline workers, and more participants of the health and wellness program. Equal representation on the committee is believed to be one of the most important things that allow informa- tion from all different departments to successfully shape the programs. Committee members are nominated to sit on the well- ness committee for a term of 1 year and can be nominated to serve again once their year has ended. This 1-year term is intended to allow more employees the opportunity to be involved in the wellness committee and to provide a fresh set of ideas every year. Once wellness committee members have accepted their nominations and are approved, they, along with their supervisor. are presented with a wellness commit- tee charter to sign. The wellness committee charter outlines the wellness com- mittee’s purpose, rules, and expectations. It describes the requirements for becoming a committee member, and out- lines specific activities that members are expected to partici- pate in during their term. These activities include volunteering for wellness program projects, recruiting and motivating other members, actively participating in wellness program events, coordinating at least 2 wellness events, and giving at least 1 wellness presentation during the program year. In addition to the activities listed in the committee charter, com- mittee members are asked to volunteer as a team captain for a health-related charity and organize a fundraising event at their facility. Target charities have included the American Heart Association’s Heart Walk and the American Diabetes Association’s campaigns. As outlined in the expectations section of the wellness committee charter, one of the most important tasks that the committee is responsible for is volunteering to complete a wellness committee project plan. Each member of the com- mittee picks an objective from a list provided by the wellness specialist at the beginning of the year, and develops a proj- ect to meet the selected objective. The committee members

183 pre sent their proposals to the entire committee, describ- ing the proposed initiative, timeline for completion, bud- get, staffing, marketing, and materials needed to effectively implement the proposed plan. The wellness specialist con- siders these proposals when designing the yearly wellness plan proposal for upper management. During the 2012 pro- gram year, the committee members proposed activities to address the following areas: • Communication, • Recruitment, • Participation/Engagement, • Fitness, • Disease Management, • Feedback, • Policy, • Nutrition, • Products, • Processes, and • Recognition. To assist with the planning and implementation of the wellness activities, the wellness specialist created the wellness communication team. These 25 people are drawn from at least 14 departments and are tasked with posting and communicat- ing upcoming wellness activities and events to employees at their respective facilities. C. Program Planning and Design The wellness committee helps with the planning for the following year’s program-specific activities. The main drivers for determining the program’s focus each year are: • Medical reports (aggregate data such as blood pressure, glucose, cholesterol, diabetes, etc.); • An aggregate pharmacy report on the drugs that employ- ees are taking, dental and vision aggregate data; • Cause of death aggregate data (listing the five main causes of mortality); • Aggregate data from self-reported health risk assessment; and • Quarterly biometric screening aggregate report. In addition, the wellness program considers participation rates, feedback from employees, and post-class evaluation forms. D. Program Elements and Implementation DART’s program is designed for the entire organization rather than specifically for transit bus operators. However, some activities are geared specifically toward transit bus operators. For example, in 2011, self-defense classes were held at each bus division due to recent attacks on DART transit bus operators. To address the needs of all employees and their corresponding shifts and work locations, the wellness program tries to offer health and wellness classes at different times throughout the day so that shift workers can have a chance to participate. Family members are allowed to par- ticipate in some activities, but family member participation in classes is not actively promoted. The DART wellness program structure is based on a point system. Employees 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 com- pleting health risk assessments, wellness workshops, fitness challenges, the wellness program kick-off, and the health expo. In addition to these activities, employees can receive wellness points for putting away a percent of their income into the DART 401K plan and for attending continuing education classes. While most of these activities can be self-reported into the system by the employees, the wellness specialist also has the ability to input points for employee participation in wellness activities and classes. Participants in the wellness program can receive anywhere from $150-$350 based on the wellness points they receive in a year. In 2012, DART began offering quadrant bundles based on the four-quarters of the year. Participants receive the maxi- mum amount of points if throughout the year they accumu- late the number of classes, online quizzes, and special fitness events equaling the amount of activities offered in one-quarter. Employees can also receive an incentive package for complet- ing 4 of 5 preventive activities. To address concerns that medical information released during the program can affect employees’ job status, con- fidentiality and HIPAA laws are stressed at the annual kick- off meeting, safety meetings, and open enrollment. At these meetings, it is explained to the employees that their health information is provided in aggregate form and that all admin- istrative staff are required to sign a confidentiality agreement that prohibits them from discussing any employee medical information. The wellness committee is responsible for ensuring that the program is a success, however, the agency’s executive team makes the decisions when it comes to the budget, when and if people can get off work to participate, and other supportive ways to improve the program such as providing volunteer leaders. The executive team is provided with participation demographics in aggregate form and personal stories to pro- mote their support of the program. The wellness coordinator feels that if the executive team buys in and supports the pro- gram, then it is more likely that the employees will feel more comfortable with participating in the program.

184 E. Organization and Integration The wellness program collaborates with other DART depart- ments to help make the wellness program more efficient and effective. There is no integration with actual health protection or occupational safety and health (OH&S) but the information technology (IT) department has been especially helpful with the creation of the online quiz feature and the online wellness tracker. These tools have helped increase shift workers partici- pation and created a more cost-effective way to encourage and track employee participation. To assist with the wellness program activities, the wellness program enlists external partners. Speakers covering a wide range of health and wellness topics are invited to come into DART and give presentations every month. The wellness spe- cialist creates quizzes that are provided for employees every month based on information from health organizations (for example, in August there was a quiz about healthy skin based on information from the Skin Cancer Society). Every year, the wellness program provides program participants with a self-care guide. Employees received The Mayo Clinic Guide to Self-Care in 2012 and blood pressure pamphlets in 2011. In other years, employees have been provided with a walking kit, a smoking cessation kit, and a food and fitness tracker. As an additional resource, employees can access online health and wellness newsletters and publications using the online well- ness program tracker. The local union does not have an official role on the wellness committee, other than individual union members serving as committee members. However, conversations with the union leaders and union members that sit on the committee are very positive. While the union leaders are mostly focused on the health insurance premiums (which are typically addressed in the bargaining process), they are glad that there is a program in place that focuses on the health and wellness of the opera- tors at the facility. However, due the very busy work schedules of union leaders in other business matters, they have not had a primary focus to be a part of the current health and well- ness committee. After participating in the F-17 case study and survey, they plan to become more involved in the future. F. Impact and Evaluation Analysis of information that is reported throughout the year from their insurance company and biometric screening company suggests that the program is successful. DART also engages in some facility targeting based on medical insur- ance data. Recently, based on their dental insurance claims, the dental insurance carrier gave a workshop at a targeted facility on the health and social implications of inadequate oral hygiene. Following this, DART arranged for a free mobile dental unit. The sign-up for the dental unit coincided with the wellness program health screenings to increase employee participation. The wellness specialist describes the health culture at DART as: “Overall, the culture of health at the DART is changing a little bit. People are starting to like the program and find it beneficial. If you walk around and talk to different people at DART, they are really enthusiastic about where the well- ness program is headed.” Participation is increasing. Part of this higher participation can be attributed to more transit bus operators being on the wellness committee. There are some big plans at DART for the future of the wellness program. The 2013 wellness program proposal will primarily be focused on lowering blood pressure by at least 2 percent through fitness, food, and education about what happens when you have high blood pressure and the risks associated with it. As part of this plan, there will also be a proposal that all employees be required to complete a nutri- tion class every 2 years with a test at the end of the class that they are required to pass. Additional activities in this pro- posal include healthy food suggestions for meetings, healthy vending machine foods, and healthy work environment. All of these ideas will be incorporated into a comprehensive well- ness program proposal and submitted to the executive team for approval. G. Summary While the wellness program is not a new program within DART, the addition of a wellness specialist has caused the pro- gram committee to be completely restructured. This restruc- turing has made the DART wellness program a well-organized program that focuses on ensuring that program participants are active in the structure of the wellness program. Wellness committee members are tasked with defining future project activities, while the communication team leads employee participation. The partnership of the wellness specialist and the commit- tee participants is a large reason why the program is success- ful. She is attentive to the needs and concerns of the program participants and tries to incorporate those into the program. However, within DART she is the sole person responsible for the wellness program and her authority is defined by the executive team, so there are limits to the program needs and concerns that she can address. However, the executive team highly values her opinion and is usually on board with the ideas that she proposes. As expected, there are some barriers to program success as it relates to transit bus operators and the operations depart- ment as a whole. While there is an attempt to schedule wellness activities for all departments, including operations, bus opera- tor schedules can make it hard for them to attend activities. Attempts to address this concern included the implementation

185 of a wellness online quiz that shift workers can utilize to gain wellness points, but it is recognized that this is not enough. Currently, DART is looking into ways to more effectively address this health and wellness program concern for transit bus operators and the operations department as a whole. Edmonton Transit: A Case Study in Work-Related Health Protection A. Background Edmonton Transit (ETS) is a public transit service owned and operated by the City of Edmonton, Alberta. They have a vehicle fleet of 949 buses and 74 light rail vehicles with 23 bus hubs and 15 transit stations. Edmonton Transit has approxi- mately 2,178 employees, including 1,536 fixed-route operators. Edmonton Transit mechanics and operators are represented by Amalgamated Transit Union (ATU) Local 569. Sources: Occupational Health and Safety Consultant Bus Operations Manager Local Union President B. Case Focus: Work-Related Health Protection and Promotion One of the key elements of a comprehensive workplace health protection and promotion program is its ability to address the multifactorial contributors to bus operator health. Programs that address workplace safety and occupational health concerns are likely to have a greater impact on health and on retention. By acknowledging and addressing bus operator concerns about work and personal health, integrated programs will be taken more seriously and be more trusted. Edmonton Transit Sys- tem demonstrates how occupational safety and health staff and committees can help protect and promote workplace health and wellness. C. Program Planning and Design The Edmonton city-wide employee health services pro- gram, part of the Employee Safety & Wellness section, employs a corporate health promotion specialist, an industrial hygien- ist, two 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 residents), educational events and health fairs, and work hazards assessments and consults. Each city department, including ETS, has dedicated occu- pational health and safety (OH&S) staff, called consultants. Among other OH&S responsibilities, the OH&S consultants work with the city-wide wellness program to disseminate information and implement initiatives. The model is one of identifying and responding to department-specific health protection and promotion needs. The occupational health and safety consultant for transportation services has a background in OH&S, in the gas and oil industry, which has transferred well to her work at ETS. Each of 4 bus facility OH&S committees consists of repre- sentatives from management, occupational health and safety, transit bus operators, and inspectors. The OH&S commit- tees analyze worksite hazard assessments, incident reports, and seasonal changes to define what health problems should be targeted. They use these monthly meetings to bring forth safety issues, assign issues to individuals for investigation, and make corrections or suggestions for improvement. A facility inspection is carried out monthly, and findings and recom- mendations are submitted to the facility operations commit- tees and then to the directors meeting for approval. Twice a year, the facility committee co-chairs, supervisors, and man- agement come together to discuss the improvements made as well as areas of future improvement. Health promotion targets are established for the city as a whole and for each division. In ETS that targeting is somewhat ad hoc: rather than systematic evaluation using health plan or other data, the OH&S committee and the OH&S consul- tant bring together observed problems, complaints, incident reports, and knowledge of health issues that are common in the transit industry to propose and implement activities for the following year. Seasonal and annual targets are set, and each month two topics are selected to cover with educational materials and activities. The departments complete an annual review and update of the program and adapt the city-wide content for employee manuals. D. Program Elements and Implementation Although agency finances have limited extensive WHPP initiatives, activities continue that link health, wellness, and safety concerns. In 2012 the ETS manager championed Charlie’s Challenge, a walking program and a running pro- gram. This was implemented based on concerns about their aging workforce and the need to stay healthy with age. Par- ticipants attended running education clinics, achieved weight loss and exercise goals, and increased their self-reported healthy food knowledge. Only 92 ETS employees participated. Ongo- ing walking groups, a major goal of the program, were not as successful. The OH&S committee discusses and initiates campaigns. The recurring slip and fall campaign, designed for the winter months, provides operators with the appropriate footwear as well as the mechanisms and maneuvers to help prevent trips and falls. The designated footwear is incorporated into the

186 collective bargaining agreement as part of the uniform paid for by the company. Winter driving training and reminders provide skills for work and personal safety. The OH&S committee aims to be proactive instead of re- active. For example, silica dust has been identified as a current hazard in transit garages as a result of using sand for deicing. Although no associated illnesses have been identified, the OH&S committee used information from the facility assessments and from other sources to prepare a silica campaign, including air quality testing to measure the extent of the problem and educa- tion about the risks and the symptoms of silica exposure. The next large health target is obesity, and sleep apnea will also be addressed. Current activities are aimed at raising awareness. The OH&S consultant recognized the difficulty of solving these problems, and notes the specific impact of schedules, including split shifts, fatigue, and limited access to healthy food. The OH&S committee consults the corporate ergonomist when input is needed. This ergonomist typically helps the com- mittee examine back problems and other ergonomic issues that operators experience to determine how these problems can be addressed during and after initial training. For example, if a bus operator is having trouble with the bus seat, the OH&S consultant will ask the ergonomist to come in and evaluate the situation, make recommendations for better adjustments, and retrain the bus operator as needed. At the same time, both the bus division health consultant and the training staff, who are also experienced drivers, have ergonomics knowledge and experience that they share to improve training and the safety environment. The OH&S division at Edmonton Transit participates in the Partnerships in Injury Reduction (PIR) program, a joint effort of the Workers’ Compensation Board (WCB), Alberta Employ- ment and Immigration, industry partners, safety associations, employers, and labor groups. This voluntary pricing program encourages injury prevention and the development of effec- tive workplace health, safety, and disability management sys- tems. The program includes regular audits that ETS uses to establish an action plan and a 3-year goal for the program. Edmonton’s partnership in this injury reduction program helps address retention and availability by paying attention to issues that result in modified duty and keeping modified duty time as short as possible. The OH&S consultant also uses the WCB website to find additional resources and educational materials on transit issues. E. Organization and Integration Wellness initiatives are influenced and implemented by the safety team, through the OH&S committee, and supported by the city-wide wellness program. The integration includes operations: Attempts are made to consider health and fatigue in developing schedules, and the transit manager participates in wellness activities. Both labor and management men- tioned the importance of operations managers as well as the OH&S consultant visiting the locations to demonstrate sup- port for health and safety in the workplace. These visits take place early and late, not just during typical business hours. The union provides input to the OH&S consultant on concerns and issues reported by members but does not yet formally serve on the OH&S committees or participate in wellness activities. Union leadership reported that participa- tion by union representatives in the monthly meetings will improve conditions and communications; they also feel that the health protection and promotion programs would be more effective if there was legislation in Alberta that required them and defined a role for the union. F. Impact and Evaluation Employee health has a direct effect on hiring, safety rules, and training. Avenues used by the OH&S committee and others with health responsibilities to influence health include func- tional capacity examination used for hiring, the implemen- tation of safety-rules structuring on bus operator/ customer interactions to enhance operator safety, and a training cur- riculum that is enhanced to emphasize health and wellness elements particularly related to shift work, work fatigue, and operator—customer conflict minimization. Regular hazards assessments and location inspections are carried out to identify safety problems. Respondents felt that the most notable data collection tool that Edmonton Tran- sit uses to identify health and safety targets are the incident reports that the operators fill out. Operators are expected to contact control when they have an incident or fill out an incident report as soon as they finish their shift. Management promotes the understanding that even apparently minor inci- dents could become a concern. To evaluate Charlie’s Challenge, the walking and running program, the health promotion specialist surveyed program participants about whether they achieved their program goals, whether the challenge created positive or healthy changes in the workplace environment, and whether partici- pants would participate in similar programs in future. This program reached only 92 transit employees, two-thirds of whom filled out evaluations. G. Summary The Edmonton Transit System does not have a stand-alone transit-specific health and wellness program. The city-wide system provides support, but it is the OH&S consultant and committees that address health and wellness concerns. ETS uses OH&S committees located at each of the transit facilities

187 to analyze worksite hazard assessments, incident reports, and seasonal changes to define what health problems should be addressed in upcoming campaigns. The City of Edmonton has a multi-year commitment to a measurable sustainable wellness program, but wellness programming is more suscep- tible to budget availability than the robust OH&S program that is provincially mandated. The strength of the program—its integration of health pro- tection and health promotion—is paradoxically linked to the need to maintain a program in times of limited resources by integrating it into the OH&S structure. But the relationship is not just one of convenience. Unlike some employers that focus on individual illness and risks, management feels “the program has to have a correlation between what the company is offering, the work that is being done, and how the activities relate to the employees.” To assure this connection, the OH&S consultant spends a lot of her time reaching out to the transit operators for their health and safety concerns and problems. All parties report a commitment to timely resolution of safety concerns, and a pragmatic recognition that operations demands and ideal conditions conflict. At the same time, neither OH&S staff nor the city well- ness program comprehensively addresses the organizational stressors of the work environment, although there are policies on issues such as assault and scheduling. The union reports that morale is not strong among operators. Some manage- ment activities aggravate the impact of the demands of sched- ule (camera surveillance), passenger assaults (limited support for those who are spat upon and discipline based on how the operator responds to assault), and work-family life conflict (aggressive sick time policy). The Union takes a role in refer- ring members for psychological support services because they feel the employers’ program does not yet adequately support members’ needs. The program could be improved by additional resources. The OH&S consultant is ready to introduce new concepts and activities. Moving forward to create an integrated workplace health protection and promotion program will also require an extended role for the Union and a recognition that health, wellness, and safety are influenced by complex combinations of individual, work, environment, and organizational factors. Orange County Transit Authority: A Case Study in Organizational Support A. Background The Orange County Transit Authority (OCTA) was formed in a merger of 7 county transportation agencies. The system employs 958 transit bus operators, working out of 3 bases and running 591 buses on 77 bus lines to every city in Orange County. Operators are represented by the International Brother hood of Teamsters Union Local 952. The program was reviewed in detail for TCRP Synthesis 52 almost a decade ago. Rather than restate that comprehensive description, this study will focus on how the program has developed and maintained organizational support along with changing conditions. Sources: Health, Safety, and Environmental Compliance Director Wellness Administrator Base Operator and Maintenance Representatives on the Wellness Committee Wellness Ambassador/Program Participant Local Union President B. Case Focus: An Integrated Program with Organization-Wide Support This is an ambitious program reporting a wide range of activities and targets. What makes it remarkable is the exten- sive support it receives throughout the organization. The program is housed in the Health, Safety and Environmental Compliance (HSEC) department, although its position has varied over the years. OCTA supports a full-time wellness administrator, consulting fitness specialists, fitness facilities, intramural sports, health fairs, an incentive program to encour- age varied participation, and mandatory wellness training. The program administrator, a Senior HSEC Specialist, also contrib- utes to ergonomics discussions and analyses. Union leadership supports the program but has not taken a large role in planning targets or activities. The Union includes health protection and promotion information in its member newsletters, and negoti- ates health benefits. C. Planning and Design The OCTA wellness program began in 1991 to reduce the costs of providing health benefits and workers’ compensation claims by slowing the rate of premium increases, to reduce productivity losses related to absenteeism, to promote health awareness and improve health, and to educate employees in the better use of services. In the original program, ambassadors—experienced tran- sit bus operators and trainers—actively promoted health by riding with other transit bus operators to observe and cor- rect biomechanical concerns, and give talks about road issues such as ergonomics and responding to passengers. They were selected based on attendance and other exemplary characteris- tics. However, the release time funding was lost following dras- tic cutbacks at OCTA, so this component has been eliminated. Currently, program path and activities are determined largely by the full-time wellness administrator. Three main inputs determine yearly goals and activities: health areas known

188 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 offered by the health plan and other resources. A committee made up of two transit bus operators from each of the three bus bases and maintenance from two bases meet monthly to discuss successes and make plans. These champions volunteer to serve on the committee with super- visory approval, or are selected by the base manager. The insurance plan representative sometimes participates in com- mittee meetings. There is some input from administrative staff but they have their own committees and activities. Human resources is involved with some health areas but has little direct engagement with wellness activities beyond providing services for the administrative staff. All parties (safety and program staff, base management, union leadership, and participants) agree that the wellness arena is one of mutual respect and responsibility, with upper level management commitment, and base managers who sup- port the program. The CEO (a competitive runner himself) strongly encourages the fitness focus, but otherwise gives the safety department and the bases a green light to move on health and safety issues. Overall, upper management involve- ment is diffuse rather than command-and-control as in many transit agencies; its presence at events is noted and wel- comed. It was suggested that stronger upper management involvement could help the program, by providing influence at the planning level, by asking questions that could drive the program forward, and by demonstrating responsibility for program development, along with support. D. Program Elements and Implementation The “Shoes and Wheels” point-based incentive program encourages healthy behavior and learning and fitness activi- ties via a web-based portal. Employees record daily physical activity and education to win health-related prizes such as hand weights or sports clothes. Health workshops are sched- uled quarterly for transit bus operators and monthly for other employees. Other activities include health awareness/ behavior change programs such as weight challenges, includ- ing a holiday “Maintain Don’t Gain” program. As an organi- zation OCTA participates in a variety of walking challenges, race participation, and family events. They are especially proud of their success in regional races. There are fitness centers in each base, 3 with a part-time exercise specialist who also provides health indicator mea- surement, coaching, and consultation. Users report that the competence of the chief trainer in exercise and health knowl- edge, and his understanding of the concerns of transit work, contributes to the program’s success. Despite this, only about 15 percent of the transit bus operators use the gym. The program negotiates health club membership reduc- tions and other health benefits. Health resources and infor- mation are disseminated in monthly health newsletters and on electronic bulletin boards at the bases. A unique weight loss incentive is found in the “Weight-Loss Uniform Set Replace- ment” contract language, which establishes that employees who have lost a minimum of 40 pounds are eligible to receive a complete new uniform set. A health risk assessment (HRA) portal, run by human resources through the health insurer, has not been well coor- dinated for transit bus operators. As initiated the computer- based system required the bus operator to login, wait for a password, and then complete a 45-minute HRA. The time required made it difficult for transit bus operators to par- ticipate during their downtime at the bases. The wellness administrator is investigating ways to make this resource more responsive to operators’ time demands and to their interests. E. Organization and Integration Workplace health protection and promotion functions are distributed across the human resources and organizational development department. The HSEC office covers health and safety hazard identification and correction and the wellness program. Workers’ compensation issues, rehabilitation, and return to work are the responsibility of risk management, and human resources covers organizational development. Sources described how the agency addresses policy affect- ing health protection and wellness, directly or through other programs: • Scheduling: “Recovery time is built into the schedules.” • Safety Rules: “We complete workstation evaluations to determine proper body mechanics for loading and unload- ing wheelchairs. We promote stretching and micro breaks during shift.” • Vendor Selection: The health promotion manager works with vending machine supplier to maintain a percentage of healthy beverages, snacks, and other foods in the machines. • Bus Procurement: “Bus equipment is evaluated to deter- mine the strain/stresses placed on the body in order to prevent back injuries and reduce workers compensation claims.” Proactively, the Health and Safety staff has been part of the procurement process when buses have been purchased, and they assist with ergonomics and safety issues for the buses. For example, program staff investigated the possibil- ity of lower extremity pain related to the ergonomics of an articulating pedal accelerator and assessed anthropometric measures for extended use. Although California law requires

189 ergonomics training only with initial training, OCTA main- tains it on a 3-year cycle. Operators are encouraged to exercise and stretch during the work day, using first a stretch program video during required safety and health training then a palm card stretch series that focused on areas of particular concern for operators. An over-extended local union leadership has accepted man- agement’s leading role in the WHPP activities, but is interested in increasing the union’s contribution to member health and wellness. The union president reports: “OCTA provides excellent training and works very hard to address health and safety matters. Unfortunately, service reduc- tions (due to lack of adequate state funding) and extreme time pressures (running late, very heavy passenger loads, no time to use the restroom, eat, or stretch) contribute to injuries (physical and mental) and excessive absenteeism.” OCTA has been working with the health care provider to track aggregate employee health status and to target behaviors that affect health. The health care provider delivers lunch-time educational materials from its existing content areas. How- ever, these programs are not tailored to the unique character- istics of the transit employee. The health plan participates in wellness meetings and provides support, for example, sched- uling doctor visits via the mobile unit and flu shots via their Healthworks program. However, events require at least 20 par- ticipants for the mobile unit and lunch sessions, these events can be hit or miss because of operator scheduling. Because of small turnout, the sessions may consist only of DVDs. The health plan has individual plans to help people set health goals, and will be actively promoting its coaching program starting in January 2013. The safety director sees family members as peers who can either support or sabotage efforts by how they encourage the worker and even how they cook at home. He wants to involve family members in promoting safety and wellness at work and outside of work. Weekly safety briefings have addressed home and holiday safety. The internal communications groups plans to include family involvement in slides for the digital signage system in the bases. The champions and activists involved in program planning and execution, many of them transit bus operators, described a traditional exercise and wellness program that they sup- ported strongly. Although they feel positively about it, most of the initiative comes from the manager. There was at times a feeling that operators did not make a strong enough com- mitment to their own health. F. Impact and Evaluation The health plan provides some data on health status and outcomes, but most of the program evaluation focuses on participation. 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 lunch-time events, allows the wellness administrator to monitor partici- pation. 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. Except for the Shoes and Wheels system, the pro- portion of operators participating is not well defined in the data. It appears that active bus operator and maintenance participation is not extensive. Less than 20 percent sign-in for the Shoes and Wheels incentives program, and about 15 per- cent in each base use the exercise equipment and consult with the health trainer. G. Summary OCTA WHPP program survives and prospers on the respect all significant parties have for each other. Despite personal- ity differences, varied time and work pressures, and different perspectives on what the most significant health issues are or how to address them, all see that the transit bus operators are affected by their work, that their health status is not ideal, and that the success of the organization depends on opera- tor safety, health, and wellness. While individuals in many agencies have espoused the same views, OCTA was unique in respondents’ unanimous support and commendation for each other. Program staff and participants critiqued the ability of the vendors and other resource organizations to provide transit- specific support that takes operator schedules and work cul- ture conditions into account. Both management and union are developing tools to address this: for example, the union has talked with the health plan about the problems transit bus operators experience with prescribed diuretics when they may have limited access to restroom facilities, and the well- ness administrator is discussing ways to increase access to health plan data and use it for planning and evaluation. Orange County and the City of Orange faced the budget constraints of all transit agencies notoriously early, which had an impact on initial wellness activities. The crunch contin- ued recently, and fiscal concerns are recognized by union and management as a core limitation in developing an ideal pro- gram. At the same time, the organization has maintained a commitment to visible and effective activities and a significant budget. Perhaps the biggest potential weakness is the reliance of the program on the initiative of a single effective individual. While the work is well-respected throughout the organiza- tion, wider involvement across the organization may be lim- ited as the manager’s role is seen as predominant. Distributing

190 responsibility for assessment, planning, and programming throughout the network of ambassadors and other active supporters could make the program stronger and ensure its longevity. It could also free up the wellness administrator to do more quantitative needs assessments and program impact evaluation. Improved evaluation could help prove the value of the program to the organization and stimulate wider man- agement support and involvement. Health protection and promotion at OCTA in the future is likely to be enhanced by the safety director who recently joined the organization. Along with the wellness administra- tor, he recognizes the potential for increasing the use of the health plan resources. Both the safety director and the union president are committed to expanding the program as an inte- grated and comprehensive approach to worker health, safety, and wellness. Recognizing that a program may be limited by a competition model and too strong a focus on individual behavior change, they plan to contribute to the development of a transit-specific culture of health at OCTA that can bring workers together. Although the recognized limits on funding could impede major changes, the program continues to gar- ner support and respect. Capital Metropolitan Transportation Authority: A Case Study in Evaluation and Return on Investment A. Background Capital Metropolitan Transportation Authority, or Capital Metro, is a public transportation provider located in Austin, Texas. Established in 1985, it currently operates 198 buses, paratransit services, and a commuter rail/light rail system. In 1992, Capital Metro created Startran, Inc., a private entity that acts as the authority’s agent in managing its unionized workforce. Capital Metro drivers and mechanics are repre- sented by Local 1091 of the Amalgamated Transit Union. Startran and the ATU have in the past had troubled contract negotiations that most recently resulted in a general strike in November 2008. In August 2012, nearly all Capital Metro’s services were transitioned to several private transit operators. With finan- cial contributions from the private operators, Capital Metro continued to provide a workplace health promotion program to bus drivers and mechanics, now employees of the private operators. This case study reports program elements and results prior to the transition. Sources: Risk Manager (Wellness Program Oversight) Project Manager (Vendor) Union Representative and Operator B. Case Focus: Measuring Program Success Using Metrics and Return on Investment Capital Metro’s employee wellness program has continu- ously measured program success using metrics and return on investment (ROI) calculations. The agency’s ability to demonstrate tangible benefits and associated financial gains reinforces the fairly substantial dedicated budget the wellness program has enjoyed through the years. Among the agencies surveyed and studied in the F-17 project, few were able to track as many and detailed measures as Capital Metro, and none calculated ROIs based on these measures. Although the methods Capital Metro utilizes could be further strength- ened, it represents one of the most comprehensive cases in transit for evaluation of the impact of WHPP programs. As part of the case study effort, researchers conducted a series of interviews with stakeholders, including the program coordinator, vendor, union representatives, and transit bus operators. Researchers also collected a complete portfolio of Capital Metro’s internal program planning, marketing, and evaluation files, including detailed descriptions of program components, incentives and results, participation tracking, employee satisfaction survey instrument and results, and ROI calculations. C. Planning and Design In the early 2000s, Capital Metro was confronted with record high health care costs, especially among operators, and greatly increased absenteeism. In 2003, they 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. At the inception of the program, Capital Metro determined that having a third-party vendor deliver the wellness ser- vices would ease operator concerns regarding confidentiality and encourage participation. This vendor provides wellness coaches and personal trainers, personalized health assess- ments, and preventive screening. Capital Metro staff over- sees the contract and enriches the program with additional health and wellness promotion elements such as health edu- cation, smoking cessation programs, healthier food options, and cash incentives. The Capital Metro Employee Wellness program was designed to address key aspects of employee health—physical activity, nutrition, weight management, stress-reduction strat- egies, and smoking cessation. Program targets and compo- nents are adjusted based on the medical claims data from the benefits department, showing top health problem areas and associated costs.

191 D. Program Elements and Implementation During the 12 months prior to the case study, approxi- mately 250 out of the 668 Capital Metro transit bus opera- tors actively participated in the program. Nearly all operators received health information mailing or attended a meeting. Initiatives of the program include: • 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 quan- tifiable health milestones, such as blood pressure reduc- tion, 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 demon- strations, wellness fairs, onsite weight loss meetings, and smoking cessation programs. Through support from the County Health and Human Services Department as well as the Centers for Disease Con- trol (CDC), Capital Metro has enjoyed a large budget for its worksite wellness program, estimated at $350,000 in the most recent fiscal year. E. Organization and Integration The wellness committee includes line managers, Human Resources, transit bus operators, mechanics, and administra- tive staff. Although several rank-and-file union members sit on the committee, the union has not officially participated in committee meetings. Management is considering a proposal to restructure the committee to recruit wellness champions from among people who have actively participated and ben- efited from the program, to help promote it. When surveying employees on how wellness activities can be designed to have the most impact, the chief complaints Capital Metro received were tight schedules that allow no time for bathroom breaks or lunch. One of the barriers to achieving maximum results is the lack of communication and coordination between departments to implement posi- tive changes to bus operator schedules. For transit bus opera- tors working a late shift or extra-board operators who do not have a set schedule, participation in a fitness class or indi- vidual training session is difficult, even though Capital Metro makes an effort to keep trainers onsite for as long as possible during the day (6 am–6 pm). F. Impact and Evaluation Capital Metro utilizes a comprehensive planning and evalu- ation template for each health promotion initiative. Detailed data from the logs, trackers, and employee surveys are plugged into the template to track process and outcomes of each new activity. Capital Metro tracks an extensive list of measures to gauge program outcomes against yearly goals, beginning with pro- gram participation and penetration rates. To calculate gym participation, badge reports are provided by security and logged into a customized spreadsheet. Each month, the well- ness center logs gym participation, personal training ses- sions, biometric assessments, fitness class participants, and one-on-one fitness consultations. All full-body assessment participants (including those taking part in fitness and nutri- tion challenges) have their data collected and stored in the assessment system. For each challenge, such as weight loss, progress of individual participants or teams is kept in a spreadsheet that calculates the percent 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. In addition to the fitness center logs, a rolling wellness pro- gram tracker tracks each individual participant in 5 broad categories of wellness activities, namely physical fitness, weight management, stress management, tobacco cessation, and mis- cellaneous wellness. Data from the tracking spreadsheet are then rolled up into monthly and yearly summaries. The wellness staff also conducts an annual employee sur- vey on their satisfaction with the fitness center staff, equip- ment, 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. Return on Investment Capital Metro is among one of the very few transit agen- cies that conducts an ongoing cost-benefit analysis of the worksite wellness programs. A study published in Preventive Chronic Disease by the Centers for Disease Control and Pre- vention in April 2009 reported that Capital Metro’s employee health care costs were reduced dramatically as a result of this program. Starting in 2003 when the wellness program was launched, until 2006, Capital Metro’s health care costs con- tinued to increase each year, but at smaller rates each suc- ceeding year and below the national average rate of increase. In 2007, when participation in the program grew dramati- cally, Capital Metro saw a 4 percent decrease in total health care costs. Similarly, rates of absenteeism among transit bus operators remained stable at approximately 10 percent from 2001 through 2005. The rate declined to 8.2 percent in 2006

192 and 7.6 percent in 2007, for a savings of $450,000 compared with the cost of the 10.1 percent absenteeism rate in 2004. The wellness staff coordinates with benefits and operations on the calculation of wellness ROI. The benefits depart- ment produces reports with the number and types of medi- cal claims and the associated claim costs, among a myriad of other measures. The top-ranked claims also inform wellness of the target areas their program needs to focus on next. The operations department keeps track of absenteeism and feeds the information to the wellness division periodically for trend analysis. Absenteeism is defined as the number of “lost hours” divided by number of scheduled hours. “Lost hours” includes absence due to FMLA, sick leave, workers’ compensation, and medical leave of absence. In 2007, the program achieved a return on investment of $2.43 for each dollar invested. Agency documents show that the ROI reached $3.95 and $2.88 in 2009 and 2010. The final ROI reports are reviewed by the Director of Finance on an annual basis. According to the management survey respon- dent, the benefit measures, especially absenteeism, are affected by a number of external factors. It is difficult to isolate the effect of the wellness activities. G. Summary With clear goals set forth 10 years ago, Capital Metro embarked on a renewed journey to improve the health and wellness of its employees, in particular transit bus operators, while at the same time achieved better efficiency and effective- ness through reduced absenteeism and health care cost con- tainment. Through the years, it has gradually expanded the program to include a comprehensive menu of complementary components. Each program activity is carefully planned out, based on the needs expressed by employees through opin- ion surveys and supportive data such as demographics and health claims. The program pays great attention to tracking the progress of each participant and any observed health sta- tus changes. Each year, program staff collaborates with the operations and benefits departments to document changes in operator absenteeism and health care cost data. Converting improvements in these key success indicators into financial terms and bringing total program costs into consideration, staff calculates the ROI and tracks its fluctuations year by year. Capital Metro is setting the pace for other transit agencies that are interested in not only implementing a program, but know- ing how well the implementation is carried out to impact the agency’s bottom line. The 2 primary outcome indicators used are absenteeism and health care costs. The program staff is well aware of the limitations in the evaluation method, given the multiple vari- ables that could also impact these measures that are not under the control of the WHPP program. A well-rounded calcula- tion of ROI would need to address the varying of degree of influence by external factors. A third measure, presenteeism, is sometimes used by model WHPP programs but is not currently included by Capital Metro. Presenteeism measures the lost productivity of employees when they attend work while sick. In the world of transit bus opera- tors, presenteeism is clearly more difficult to measure than absenteeism, and probably more difficult compared to occu- pations such as production workers. With the Startran transit bus operators now becoming employees of private contractors, significant coordination will be needed from multiple divisions of Capital Metro and the contracting companies for the program to continue its success and its evaluation effort. Union involvement may become even more challenging, given the complexity of the relationship going forward. United Transportation Union—Los Angeles County Metropolitan Transportation Authority Wellness Program: A Case Study in Maintaining Effectiveness with Growth A. Background The Los Angeles County Metropolitan Transportation Authority (LACMTA) employs 5138 transit bus operators represented by the United Transportation Union Locals 1563, 1564, 1565, 1607, and 1608. The system encompasses 10 bus bases and a total of 9,200 employees. Sources: UTU Trust Fund Manager UTU General Chairman and five Divisional Chairpersons Deputy Executive Officer of Human Resources Human Resources Director 2 Program Ambassadors 5 activity participants (including 2 from Service Scheduling) Wellness Committee participants B. Case Focus: Maintaining Effectiveness with Growth The UTU-LACMTA health promotion program dem- onstrates how an organization can start small and grow while retaining activities and a focus that are location-specific, making use of individual and system-wide resources. It has developed from a pilot project at 2 of 10 bus locations into a comprehensive effort that shares its success with other divi- sions and titles. This 6-year-old traditional wellness program is staffed and run by the United Transportation Union Trust Fund, which administers the health and welfare benefits for LACMTA transit bus operators, and is supported by the

193 health plan and other vendors and community groups. The program is guided by explicit and quantitative 4-year strate- gic plans defining targets, activity, evaluation, and outcome goals. It covers employees in all sectors of the organization as well as family members and includes family activities. The LACMTA health and wellness program was estab- lished by the employer with the support of the union as a pilot project, then transferred to the Union Trust Fund. It stands out in the transit industry for the extent of available resources and in the level of local union support. C. Planning and Design The UTU-LACMTA Trust Fund labor-management col- laboration began in 2007 to control escalating costs without reducing benefits. The Board of Trustees asked its benefits con- sultant to develop a strategy to improve employee health and to control health plan premium rates and self-funded costs. Strong senior support was obtained from the Union Gen- eral Chair, all Local Union Chairpersons, and the LACMTA Chief Operating Officer, Chief Financial Officer, and Direc- tors of Human Resources, Benefits, and Safety. Following a pilot in two divisions, the UTU Trust Fund decided to fund the program manager position to direct program activity and coordinate planning with management and the other unions. The program has since expanded to all bases and the agency headquarters. The Wellness Committee was developed in 2008, composed of UTU and LACMTA trustees, union leaders, LACMTA department managers, and health plan representatives. Cor- porate safety remains aware of the program but has recently had little time to spend on issues beyond system safety. A local union chairperson was initially appointed as the well- ness committee chair. The trust fund manager, the 5 UTU divisional chairs representing the transit bus operators, and other union representatives participate actively in planning and supporting program focus and activities. The Wellness Committee establishes strategic plans covering 3–4 year periods and yearly goals after looking at health plan data, other health indicators, participation by divisions, and avail- able resources. Extensive external partner involvement was also obtained, including financial, staffing, and resource support from all health vendors, and information and training from com- munity organizations. Vendor contributions cover incentive programs, health fairs, program supplies, travel, printing and copying, program shirts for ambassadors, and meeting costs. Budget needs have increased as the program grows. The fund administrator asks for percent increases on the agreed con- tributions when negotiating contracts with carriers. These monetary and in-kind contributions benefit both carrier and the Trust Fund as they increase overall health and make insurance use more efficient. The divisional chairs approve and monitor the divisional wellness Ambassadors, hourly employees at each location responsible for carrying out wellness activities to suit their locations. The LACMTA covers release time for the Ambas- sadors and other staff for activities and meetings. Currently the LACMTA covers release time for 18 Ambassadors every other Wednesday for 4 hours. Division Managers are iden- tified as Wellness Champions to support Ambassadors and participate in division-based Health and Wellness commit- tees, and have discretion to release Ambassadors for longer as needed. Ambassadors: • Help carry out and evaluate the worksite program. • Maintain the communication, tracking, and evaluation systems for the program. • Facilitate health, fitness, and nutrition-related programs for groups and for individuals. • Support the fitness facility by supervising the exercise floor and ensuring a safe environment. • Provide fitness center orientations of gym equipment to new members. • Solicit input from other hourly workers about health needs and concerns. • Develop and run site-specific activities. D. Program Elements and Implementation The program initially focused on prevalent issues of pres- enteeism, upwards trends of workers compensation claims and avoidable accidents. Most activities target physical activ- ity, nutrition, and disease management. Targets are based on the current strategic plan and annual plan and previ- ous year health fairs outcomes and evaluations. The pro- gram attempts to maintain activities with good participation and at the same time keep the offerings fresh. Initiatives are also identified in quarterly meetings of site champions and ambassadors. Aggregate health risk assessment data is used to target site-specific activity. Within each division, activities are coordinated by the union local chairperson and division managers. Specific activities are selected in part by the ven- dors who sponsor and run “Lunch and Learn” events. Quali- tative input is provided by member testimonials, quarterly meetings of site champions, and the annual plan for each year. Because the program allows for adaptation, location Ambassadors can respond to local needs and resources—one is a certified popular exercise instructor, another prepares food to sell and uses the proceeds to purchase exercise videos and playback equipment.

194 Program activities include lunch and learn events at all locations, wellness coaches to review screening results with participants, contributions to the company’s safety TV net- work, a mobile vehicle with an occupational physician famil- iar with the demands of transit work, challenges and other participatory health activities including hula hoops and jump ropes, and 4–5 health fairs annually. A 6-week family exercise plan targets family health costs and rising childhood obesity, providing employees who commit to exercising weekly a bas- ket of exercise aids and encouragements. This plan is paid for by the group health vendor. Not all valuable supports are designed to benefit transit bus operators: for example, day care resources at the downtown Gateway location that could reduce work-family conflict and stress are not conveniently available to many transit bus operators and other employees who work in divisions up to 50 miles away. Onsite challenge activities are designed to encourage phys- ical movement during work. Operators are taught to use exer- cise bands with a set of exercises that can be done on the road, as well as pretrip stretches. Although the pilot phase included an ergonomist to watch posture and have people talk about pain and movement, this is no longer an emphasis area for the program. Financial incentives for participation include time off, cash or gift cards, individual prizes, and group rewards. Transit bus operators resisted the introduction of health risk assessments, in part because of concerns about confi- dentiality. As the health plan confirmed that the informa- tion provided in these assessments could be harvested in the aggregate from their existing data, this program was elimi- nated. Screenings are still carried out at health fairs, but these serve more to encourage individual awareness and stimulate change than to provide a picture of the health status of the employees. E. Organization and Integration The program is an ongoing collaboration among the unions, the vendors, and management especially via human resources and the division managers. The involvement of the division managers varies with the individual and loca- tion, and could be enhanced, according to all sources. Union officers and Trust Fund staff remain closely involved with the program and voice great confidence in the program manager who is by agreement a neutral party. Because the program is run by outside agency departments, the program does not directly address return to work accom- modation, training, safety, or other areas of a comprehensive health protection and promotion program. The program man- ager reports that “human resources, manpower and operations are extremely involved with our program, and corporate safety (as much as they can be). I am looking to get involved more with training.” The program has focused on individual health concerns and skills more than occupational contributors to health problems, work organization stressors, and workplace safety and health concerns. Notably, the HR director was responsible for a sleep apnea initiative. Union leaders reported concern that the program does not address core issues affecting operator health, especially route schedules, stress, and access to food. It is difficult for many operators to participate in the lunch events and other classes, unless they have unpaid layover time in the middle of the day. The program committee recognizes the occupa- tional challenges to health, including seated work, stress, and demanding schedules. Service Scheduling staff were aware of the demands of schedules on operator health, in particular the effects of limited break times and access to restrooms. They try to account for the stressful effects of late runs, school let out times, and for increasing numbers of wheelchairs and walk- ers, and they include extra minutes for bathroom distances at layovers. The scheduling department sets up tables to get input about schedule problems in each division 8 times a year. But they also report that they are constrained because adding recovery time beyond the contractual 6 minutes or 10 percent of the run affects revenue hours. F. Impact and Evaluation The program uses aggregate health status data from the carriers, comparing it periodically both to negotiate rates and to plan program targets. Reports from the carriers include prevalence of chronic health conditions and utilization data. Evaluation is also done through program participation rates, participant feedback, and qualitative input from Ambassa- dors, Champions, and others involved in program implemen- tation. The program identifies and describes success stories to illustrate the program impact to support their quantitative analysis. There is no formal return on investment analysis, but informally the program manager expects a positive return within 36 months, based on health care claims cost, produc- tivity improvements, and employee availability changes. The program is showing results. Although rates of hyper- tension, diabetes, and obesity are still higher than the general population, they decreased slightly in LACMTA employees between 2009 and 2011, as did inpatient admissions, out- patient visits, and prescriptions filled per 1,000 subscribers. From 2009 through 2013, the Trust Fund’s annual rate increase averaged 7.0 percent, compared to the provider’s Southern California average of 7.4 percent. The 2013 rate increase is 3.8 percent, compared to the plan’s overall average of 6.0 per- cent. The goals to keep any increase to less than 5 percent and less than the CA average were met. The program is realistic in its participation goals, aiming to attract 10–20 percent participation in each of the major activities; currently 25–32 percent of the target population

195 actively participates in at least 1 activity each year. About 50 percent of transit bus operators participate, 31 percent engaging in disease management activities, 7 percent in weight loss or exercise challenges, and 24 percent using worksite exercise equipment or off-site gym access. The strategic plan continues to set increased numeric goals. G. Summary The UTU-LACMTA Wellness Program is a well-supported, well-organized program that sets reasonable, measurable goals and meets them. The goals are established though yearly planning and 3–4 year strategic plans. It has developed from a pilot project targeting 2 bus locations to an agency-wide pro- gram that adapts to overall and local needs. The program now reaches all 15 bus locations and the Gateway building (head- quarters); the final expansion will be to include the mechanics in the program. The program’s success may be related to the unique posi- tion of the program and the program’s manager in the Trust Fund. It has allowed freedom from other HR and managerial concerns, but at the same time requires the operators’ union to provide support for a program serving more than twice its own membership. Despite the project’s roots in transit bus operators concerns, the expansion into all other titles and divi- sion risks redirecting the program from their specific needs. As the program grows the program manager is concerned about trying to keep activities in balance, not to lose track of the kinds of cooperation and planning that made the pilot study and early years a success. Several features keep the pro- gram responsive and effective. The Ambassadors at each loca- tion can adapt the program activities to the needs of their coworkers, and they can make use of their own skills and resources. The extensive and productive wellness committee enlists real participation from all interested parties and ties the program to its base, facilitated by a leader with insight and patience. The effectiveness of the project manager is both a strength and a potential weakness. All parties—management, unions, vendors, Ambassadors, and members—attribute the program’s success to the character and skills of the program manager. She trains and encourages excellence at all other lev- els of the program. However, there may not be a simple way to maintain the program effectiveness if she were to move out. The program faces the same barriers as all agencies to an integrated WHPP program for transit bus operators. Fatigued and time-challenged operators still have a hard time making use of the program resources; office staff may find participat- ing easier. Most critically, organizational contributors, such as schedule stress, work-family conflict, and ergonomics chal- lenges are not within the program’s sphere of influence. Man- agement and wellness program staff at LACMTA are aware of the limitations and attempt to overcome the divisions between these related areas. At the same time, they recognize and continue to promote the success and effectiveness of the program as it stands. Small Agency Programs: Characteristics and Challenges A. Survey Findings Small transit agencies were defined in the survey as those with fewer than 4 million annual passenger trips. Using this definition, 39 small agencies responded to the survey, each employing fewer than 180 transit bus operators. Workplace health protection and promotion were not com- mon in smaller agencies. Most had never had a program and are not planning to start one in the future. More than half of all responding agencies reported an active worksite wellness program, but only 31.7 percent of the small agencies currently have one (Table 23). The design of the small agency programs also tended to be more conventional than comprehensive, with limited offerings. Staff time commitment and program budget were significantly less than in medium or large agen- cies. One-third of the small agencies assigned a dedicated staff member, who dedicated on average only 13 percent of regular Program Status Count of Small Agency Programs N Percent of Small Agencies Percent of Total Responding Agencies Yes, active 13 31.7 55.6 Not currently active but plan to restart 1 2.4 4.6 Not yet, but plan to have in the future 3 7.3 5.6 No to all of the above 24 58.5 29.6 Total small agency responses 41 Table 23. F-17 survey respondents: count of programs—small agencies versus total responding agencies.

196 work hours to the program. In contrast, across all responding agencies, 68 percent of agencies had a program administra- tor with an average of 38 percent of full-time work spent on the program. Small agencies spent on average $3,326 annually for worksite wellness programs, compared to with $66,413 for medium-sized agencies, and $136,468 for large agencies. Several small agencies had no budget for health promotion activities because of tight resources. These agencies did not operate a stand-alone workplace health promotion program, but rather provided health promotion activities as part of the health insurance benefits through their insurance partner. A larger proportion of small agencies with existing pro- grams estimated that all or most of their transit bus operators participate (33 percent vs. 17.5 percent among all responding agencies). This may be attributable to the fact that smaller agencies employ fewer transit bus operators, who are less dis- persed and easier to reach. Interestingly, small agency representatives provided a more positive view of their health culture, both in support and orga- nizational aspects, especially compared with large agencies. For instance, small agencies were more likely to have a long- term strategic plan for their health and wellness programs, responded better to changing needs of their employees, and integrated better with other organizational areas. Transit bus operators and employees from different functions of the orga- nization were also more likely to be involved. Of the 18 small agencies that responded to the question, about one-third had a wellness committee. The most frequently mentioned com- mittee members were human resources, top management, line managers, and transit bus operators. Although in the small agencies union leadership was considered more supportive for employee health promotion initiatives in general, union representatives participated in wellness committee activities in only 1 out of 3 small agencies. B. Small Agency Case Examples Because of the general lack of dedicated resources and per- sonnel for program implementation and maintenance among small agencies, fewer small agency survey respondents were able to invest time needed for a full-scale case study, even after repeated outreach attempts from the F-17 research team. To capture more details of small agency practices, the team conducted a series of brief interviews with management and, where possible, union representatives as an alternative to in-depth case studies. These were discussed in the previous section, F-17 Case Example Catalog. These case findings cor- roborate the survey statistics across responding small agencies. Small agencies featured in the case examples implemented a wide spectrum of practices, from health education material distribution only, to providing a complete menu of activities including fitness, health screening, disease management, and financial wellness. Examples of innovative program activities offered by these small agencies included a wellness mobile unit for biometric screening and health risk assessments, personal financial health education and planning, alternative health fairs and resources, and nutritionist consultation. Most of these small agencies were fully aware of operator health issues and had a strong desire to provide additional pro- grams to improve their health status. However, budget con- straint was a major barrier that may exert a greater impact on small agencies. At the same time, small agencies are struggling with many of the same issues that larger agencies face when it comes to tight bus operator schedules that make it difficult to involve them in regular wellness activities. Generally they had an adversarial labor-management relationship that hindered effective partnership to improve operator health and wellness. Several small agencies involved in the case examples have effectively reduced health care premiums by fulfilling employee participation goals in programs provided by the health care provider. At least one agency uses data extensively to assess pro- gram needs, track progress, and evaluate outcomes. Issues Facing Multi-Agency Programs Transit agencies may choose not to implement home- grown health and wellness programs for their employees, but rather to participate in programs offered by the city, county, or state government. The F-17 survey found that 1 out of 4 tran- sit agencies that offer any WHPP program did so through “municipal, multi-agency, or other coordinated program or campaign.” The benefits of piggybacking on a state, county, or municipal program are evident. It requires little or no finan- cial investment from the cash-strapped transit agencies. Staff, equipment, and resources are more abundant. Economy of scale and higher bargaining power when it comes to negotiat- ing vendor costs are also taken into consideration. However, some disadvantages may prevent these programs from effec- tively serving transit bus operators—a unique occupational group with distinct work environment and health concerns— to the fullest degree. Multi-Agency Case Examples The F-17 research team investigated the details of one par- ticular county-wide program, collecting information, data, and opinions from both management administrators and union representatives. Like the other transit workplace health promo- tion programs, the multi-agency program was mostly initiated to tackle the nation-wide problem of increasing health care costs. In the 3 years prior to implementation of the program, medical benefits for the county’s full-time employees went up 33 percent. To address this problem, the WHPP program focused on incentivizing employee and spouse participation in a variety of individual actions to improve health by reduc-

197 ing the annual maximum out-of-pocket medical expenses. In order to qualify for the lowest level of out-of-pocket expenses, employees and their covered spouses have to participate in a confidential wellness assessment and a follow-up pro- gram aimed at helping them reduce their health care risks. Employees are required to log their progress in an online sys- tem or keep track on paper. On the basis of the risk assessment results, the contractor hired by the county assigns employees to the low-, medium-, or high-risk categories. Those in a low-risk category are asked to fill out an 8-week log of eating or exer- cise to qualify for the lowest level of out-of-pocket expenses. Those considered medium or high risk are given the opportu- nity to participate in an over-the-phone coaching program and an individualized action plan. The coach works with them to identify steps they can take to reduce risks, including smoking cessation, exercise, or stress reduction. Employees who make an effort to work on the action plan will also be eligible for the lowest level of expenses. Program administration is centralized through the county HR department. However, there is a strong sentiment from operators that the program is not designed for blue-collar employees who spend most of their work days in front of a steering wheel instead of a computer. Some of the operators are not com- puter savvy and could not tolerate going through extensive paperwork in the first few months of each year to qualify. Some employees also fear that their personal health informa- tion is not kept confidential. The union representative inter- viewed for this study feels it is important that a program be voluntary and reward participation instead of financially punishing employees who do not to participate. An indepen- dent study conducted by the union’s consultants shows that while 90 percent of the county employees have earned the best class for out-of-pocket expenses, only 56 percent of the union members have achieved that. Management acknowledges that the major barrier to pro- gram success is that the program is primarily online and it is more difficult for operators to become involved because they are out on the routes all day. Although the program is known to have generated tangible results in improved health status among some employees, it is not specifically designed for transit bus operators or even transit employees. Participation and outcomes are not tracked for operators as an employee group. There is little direct feedback from operators on their preferences. The joint labor and management committee on safety and health deals more with safety and ergonomic design issues of buses or workstations, and is not involved with the design of the broad health promotion program. Even though the individualized action plan may address common health problems of operators, this approach cannot achieve the type of division-wide health culture change that often accompa- nies well-designed transit-specific programs. An alternative model is being tested by some governments to achieve more involvement and better results from specific employee groups using pooled resources. In one state’s imple- mentation of this model, employees managing a state govern- ment’s health plan and experts from the Department of Public Health and the Department of Health and Human Services collectively designed a worksite health and wellness Toolkit for use by worksite wellness committees in all government entities. Employers can use the toolkit to build customized wellness pro- grams. The health plan is also funding a worksite wellness team at the Department of Public Health to offer new resources and technical assistance to support committee sustainability at these worksites. These services include a Web site, semi- nars, a newsletter, and a consultation program. Prior to the launch of the Wellness Initiative in one pilot department, each division, office, and facility designated a Wellness Rep- resentative. The department’s Wellness Director helped all the representatives establish wellness committees and develop tailored agency wellness plans. The Wellness Rep- resentatives also serve as members of a new department- level Wellness Council to advise the secretary on worksite wellness policy issues. The Well ness Director provides con- tinued technical assistance, which includes onsite visits to help wellness committees implement programs geared to the needs and interests of their employees. This type of top- down and bottom-up approach ensures that best practices and resources are efficiently shared among all government agencies, whereas the detailed program design is custom- ized based on the needs of employees at each workplace. The capacity is developed from within, rather than forced down from a higher level outside entity.

From Industry Practice to Best Practice Cataloging Effective Transit WHPP Practice There is some consensus on the types of interventions that are most likely to be effective in the American workforce, but the research evidence base strongly supports only a few. The CDC-led Community Preventive Services has identified a limited number of worksite health initiatives that have been shown to be effective (Task Force on Community Preventive Services, 2010): • Assessment of health risks with feedback (AHRF) to change employees’ health plus health education with or without other interventions. • Obesity prevention: worksite programs to control over- weight and obesity. • Point-of-decision prompts to encourage use of stairs. • Creation of or enhanced access to places for physical activity combined with informational outreach activities. • Smoke-free policies and tobacco use incentives and compe- titions when combined with additional interventions. • Interventions to promote seasonal influenza vaccinations among non-healthcare workers with onsite, reduced cost, actively promoted vaccinations. Although lacking definitive support in the research litera- ture, many other practices and interventions have an impact on the health environment and eventual health outcomes. Targeted initiatives in transport workers have produced mixed results, but some studies show that health education, disease management, and environmental changes can have impact on health behaviors in transit operations, as discussed in the lit- erature review (Chapter 2). WHPP programs do not typically implement 1 practice at time, so assessing each practice is not possible. In addition, whereas behavior change can happen quickly, it can take years to have a measurable health impact, even when the program is steadily maintained and the work- force does not change. Programs activities, and how they are carried out, change faster than their impact can be measured. Thus other more global measures of success such as overall program participation or cost savings are typically used. WHPP program staff, supporters, and activists who were surveyed and interviewed described practices that they believe work for them. These typically focused on health awareness, health risk assessments, disease management skills, and group activities to reduce individual risk factors such as weight or overall fitness. These practitioners and their transit agencies also facilitated health protecting and promoting changes in the health culture and the work environment, most frequently ergonomics assessments and changes. This chapter reports on the policies and activities used in transit health protection and promotion, and describes the process of identifying best practice in the transit workplace. Given the limited support- ing data for the success of specific activities provided by our respondents as well as the difficulties in measuring health impact, it was not possible to rate practices for proven effec- tiveness and feasibility in the context of transit operations. Reported WHPP Practices Agencies reported a variety of activities in the F-17 sur- vey. Traditional wellness communication modes and targets are reported most often (education, screenings, counseling/ coaching, HRAs). The health and wellness targets—nutrition, supports for a healthy environment, alternative health, and exercise facilities—follow closely. But occupational health and safety changes are also seen in about half the locations. Other programs are responsible for related activity, solely, or in tan- dem with the WHPP program, especially in occupational health and safety, HRAs, policies that support a healthy envi- ronment, and workforce development. Among the 5 unions that run their own programs, all types were reported but the scope of each program was somewhat limited. It should be noted that the tenor of the survey directed responses toward C H A P T E R 5 198

199 health—clearly all organizations do health and safety activi- ties, as do most unions, but usually not in the context of the WHPP programs. Table 24 lists the response distribution for “What health, safety, and wellness activity does your agency carry out?” Activities addressing weight management and nutrition are the most common activities reported in the active pro- grams, as shown Figure 7. Although “Biggest Loser” competi- tions were popular despite the limited evidence for long-term impact, in follow-up discussions respondents frequently emphasized that they implemented weight loss activities and challenges in the context of fitness and exercise. Tobacco ces- sation is next in frequency; although targeting a more limited population, this has both a long-term impact that cannot be measured easily but also an immediate impact on respira- tory infections in ex-smokers and families (Brook, 2011) and heart disease events (Lightwood & Glantz, 1997). The average level of participation by transit bus operators was about 25 percent in the 33 agencies that reported this infor- mation. Because so few provided data, the averages reported Activity By WHPP (percent) By Other Program (percent) (N = 45) By Union Program (N = 5) Educational messages and information 84.6 11.1 2 Educational classes and events 78.8 11.1 1 Health screenings 69.2 17.7 2 Counseling/coaching 65.5 24.4 1 Health risk assessments 63.5 33.3 2 Support for alternative health 61.5 13.3 2 Policies that support a healthy environment 57.7 26.7 1 Nutrition (healthy choices/availability) 57.7 6.7 1 Onsite exercise facilities or programs 50.0 17.8 2 Occupational health and safety 48.1 31.1 2 Workforce development 32.7 33.3 1 Subsidized offsite exercise 25.0 14.9 1 Organizational changes 11.5 20.0 0 Table 24. F-17 survey respondents: activity types reported by transit agencies. Figure 7. F-17 survey respondents: activity content areas.

200 • Improve healthy food access and choice. • Increase physical activity. • Improve ergonomics and reduce musculoskeletal disorders. • Prevent and manage fatigue. • Eliminate or reduce the impact of hazardous and stressful working conditions. The programs selected and applied the health targets in the context of the agencies’ financial, operational, and health and safety culture priorities. Tables 26a-g illustrate the wide application of health protection and promotion in transit agencies across the US and Canada. As noted, they include a few practices that have not yet been implemented that were suggested by respondents, SMEs and academic partners, and others contributing to the F-17 research process. Defining Effective Transit WHPP Practice How Do Transit Agencies Compare to Recognized Standards of Effectiveness in WHPP? According to the NIOSH Total Worker Health™ (TWH) model, there are 20 essential elements of effective workplace programs in 4 categories. Here is how the transit industry shapes up to each of the elements: Organizational Culture and Leadership TWH Element 1. Develop a “human-centered culture.” Most respondents who were directly responsible for WHPP in Table 25 are for the proportion of operators reached in the agencies reporting data for that activity, rather than the percent of the total population at risk that participates in program activities. Passive promotion activities such as mailers were reported to reach almost 100 percent of the targets, and 60.5 percent of the transit bus operators partici- pated in required worksite health meetings. In the agencies that reported participation, about a quarter of the operators requested health information, completed a health risk assess- ment, did some form of disease management, and participated in program assessment or improvement. Use of exercise equip- ment and optional workshop participation was lower. In interviews and site visits it was clear that participation was not high in most activities that required time commitment out of work. The difference between reach (participation size and range), effectiveness (the impact of the intervention on targeted outcomes), and adoption (how widely the program elements are delivered) remain important considerations when design- ing programs and activities that facilitate participation for tran- sit bus operators. The application of these concepts in WHPP program planning and evaluation as described by the RE-AIM model (Alperovitch-Najenson et al., 2010b) is discussed in Chap ter 6: Program Evaluation and Return on Investment. Health Protection and Promotion Targets and Transit-Relevant Practices Transit agency program components and activities were designed to meet one of the major health goals: • To help diagnosis, treat, and manage health problems. • To improve safety and health at work and at home. Role Operators (%) Agencies Reporting Participation Data (no.) Received mailings 94.5 20 Attended required worksite meetings addressing health promotion 60.5 16 Participated in other activities not listed 30.8 7 Participated in disease management activities 25.7 13 Participated in WHPP program assessment or improvement activities 25.1 21 Requested health promotion program information 25.1 14 Completed a health risk assessment (HRA) 24.8 21 Utilized worksite exercise equipment or off-site gym access 19.2 19 Participated in weight loss or exercise challenges 15.6 19 Participated in an optional class offered by the program 11.4 17 Table 25. F-17 survey respondents: participation in WHPP activities (864 operators from 38 agencies).

201 Table 26a. F-17 health practices. 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) Table 26b. F-17 safety practices. Goal: To Improve Safety Behavior and Decision Making 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

202 activities demonstrated a commitment to this principle, show- ing sensitivity and insight about what mattered to individuals. However, the programs they promoted did not always have flexibility in the face of operations, budget, or other organiza- tional constraints to be as human-centered as desired. TWH Element 2. Demonstrate leadership. This varied dramatically, with some WHPP programs driven by a leader- ship committed to comprehensive worker health protection and promotion, others relegated to an over-extended human resources department and provided with little support. TWH Element 3. Engage mid-level management. Ambassador/Champion programs and similar initiatives were employed to recruit and perhaps sometimes force involvement of middle management. However, organizational Table 26c. F-17 healthy food practices. Goal: 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 Nutrition program that has been adapted for truck drivers 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 health 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 A celebrity chef campaign with trucks and restaurants, serving food endorsed by the American Heart Association (suggested) Support healthy food choice Schedule group meetings to support food choice at times and locations operators can meet Popular weight loss program (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 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 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 educate their physicians about transit work demands considerations for operators, including night eating

203 Table 26d. F-17 physical activity practices. Goal: Increase Physical Activity Objective Approach Best-Practice Examples Improve individual exercise opportunity Make exercise opportunities availability for all work schedules Bicycle loan program Hula hoops and jump ropes on site 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 work Stair access and stair competition (but many transit buildings are not multi-level, and security concerns can block stair access) stair counting campaign 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 Cable car operators developed a set of exercises to do while waiting for a turn around Table 26e. F-17 ergonomics and musculoskeletal practices. 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

204 barriers, especially between HR and operations, meant that programs were often run with no input or support from the very people who were needed to ensure success. The verti- cal chain of command common in transit also impeded lateral support. Note: The NIOSH model does not explicitly include the critical role of union leadership in establishing and nurturing the programs. However, the Senior Medical Officer of NIOSH’s Total Worker Health™, recently emphasized, “Collaboration between labor and management in a participatory fashion in program design and execution is equally critical. Health pro- motion has historically been ‘if you build it, they will come.’ In reality, it’s ‘if we build it, we will come’” (Chosewood, 2013). In transit agencies surveyed and interviewed for this study, there is a distinct difference in participation and targets when union officers respect and are involved in the program. Union leader- ship should be seen as essential to success. Program Design TWH Element 4. Establish clear principles. Some pro- grams had explicit and well-considered strategic plans, but many seemed to either follow a laundry list of activities or simply bounce from one initiative to another. Table 26f. F-17 fatigue practices. 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 Table 26g. F-17 hazards and stress practices. Goal: Eliminate or Reduce the Impact of Hazardous and Stressful Working Conditions Objective Approach Best-Practice Examples Develop coping skills Public work Passenger Reporting methods Participation in problem solving 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 Schedule stress 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 Confidential near-miss reporting system Inspections to include road hazards as well as vehicle safety and onsite

205 TWH Element 5. Integrate relevant systems. Most respondents recognized the need for better integration across departments. They did not take advantage of or even have access to data and resources that would make integration possible. The WHPP programs described in the case studies illustrate how successful organizations called on the skills and knowledge across disciplines. TWH Element 6. Eliminate recognized occupational hazards. Some respondents described innovative ways to address occupational hazards and health concerns together. However, for many agencies, the sole focus of the WHPP program is on the individual risk factors and behaviors. For labor, traditional health promotion seems to encroach on their personal lives without addressing the occupational con- tributors to health problems. Occupational hazards were not typically under the control of staff responsible for WHPP; however, failure to address occupational health factors was the most common reason for program inadequacy provided by the union respondents. TWH Element 7. Be consistent. Some organizations defined a consistent approach, others modified their goals and activities intentionally or sometimes without a clear rea- son. In a very few, activities were repeated despite lack of sup- port or participation because people expected them to occur. TWH Element 8. Promote employee participation. While increased participation in program activities is a uni- versal goal, it was not achieved. Further, participation in plan- ning and revising program targets and activities was typically limited to program staff and committee members. An area to explore is how to develop effective participation through work- force development and training, such as ergonomics skills or other specialized knowledge. TWH Element 9. Tailor programs to the specific work- place and the diverse needs of workers. As noted elsewhere, this is the greatest single need expressed, after resources and increased participation. At the same time, many transit- tailored program components and activities were described. TWH Element 10. Consider incentives and rewards. While popular with agency program staff and with agency leaders, union respondents sometimes found incentives trivi- alizing or even punitive. Regulations promulgated under the Affordable Care Act define the need for incentives to be equita- ble and not punish or discriminate on the basis of health status (Health and Human Services, 2013). In addition, because they are related to conditions of work, pay and benefits, incentives, and rewards are typically subjects for collective bargaining. TWH Element 11. Find and use the right tools. Some agencies looked for and used assessment, tracking, and inter- vention tools from vendors, others developed their own. Sophistication in this area varied widely. TWH Element 12. Adjust the program as needed. Res pondents reported a variety of contradictory methods for adjusting—they repeat or terminate popular activities, continue components that employees resisted or suspend them, and some just change for the sake of changing. TWH Element 13. Make sure the program lasts. Respondents asked for help in this area as well—respondents stated that as resources in transit operations shrink, evidence for success and methods for maintaining initiatives are ever more important. TWH Element 14. Ensure confidentiality. Although taken as a given by the program staff, this was reported as a main area of suspicion between labor and management. Because bus operator fitness for work depends on health status, confidentiality concerns must be taken seriously and resolved to all parties’ satisfaction; this has not happened in many agencies. Program Implementation and Resources TWH Element 15. Be willing to start small and scale up. This commitment is illustrated in many of the case examples. Agency staff and unions were realistic about their current capacity, and understood the need to plan for growth. TWH Element 16. Provide adequate resources. Many but not all respondents cited limited resources and a need to prove return on investment as challenges. Some described having to scale back because of cuts, and several talked about transferring responsibilities to safety committees or opera- tions as a result, which might paradoxically improve program success through better integration. A realistic recognition of current limits of size and resources seemed to make programs more secure about the potential for growth when conditions improve. TWH Element 17. Communicate strategically. Com- munication from the WHPP programs to the participants was more common than the other direction. Some respon- dents were very effective at communicating with those they needed for support, data, and input. Many felt trapped in silos of influence and information. TWH Element 18. Build accountability into program implementation. Because of the importance of longer-term health impact, immediate health change is not typically used as a basis of accountable practice in the transit agencies sur- veyed. At the same time, WHPP program staff and supporters are aware of the need to provide evidence of effectiveness in a

206 timely way. Some transit agencies are able to strengthen their programs by assigning responsibility for activities to super- visory and location management. But, unlike in safety initia- tives, supervisors and management ratings are not based on health activities or outcomes. Program Evaluation TWH Element 19. Measure and analyze. Agencies dem- onstrated a wide range of techniques, understanding, and skills in this area. As described above, evaluation, including return on investment, was the weakest aspect of most pro- grams. But the agencies and unions provided a wealth of qualitative information that showed how they learned from experience. TWH Element 20. Learn from experience. The large number of committed WHPP practitioners and support- ers demonstrated a commitment to learning and adapting. What they learned included a lot about what doesn’t work. For examples, while health risk assessments were popular, some agencies found they were redundant with health plan offerings, or even led to conflict. Several locations found that competitive weight programs were popular but did not lead to sustained weight loss. The learning from experience was sometimes based on quantitative evaluation, but more often on judgment. A Model for Transit WHPP Practice Successful WHPP in the transit industry depends on the quality of the program planning and implementation. It may also be influenced by the agency’s health culture and even the local health climate, including the physical geography and weather as well as cultural variations. Success is a function of organizational characteristics including management style, labor-management relations, safety culture, and the opera- tional and physical environment. All of these are affected by available resources: money, time, information, and qualified staff. The effective implementation of best practices relies on groups of individuals working within organizational capaci- ties and constraints to ensure health-enhancing conditions and environment. Most proposals for best practices in WHPP cover core pro- gram planning concepts and provide guidance on individual health and disease management (Grossmeier et al., 2010). More comprehensive approaches take the next step of inte- grating WHPP and occupational health and safety concerns in a generic workplace, or in a specific setting such as health care (Blix, 1999; McLellan, et al., 2012). The Total Worker Health ™ model promoted by the NIOSH (Centers for Disease Control and Prevention, 2013) provides broad guidelines and 20 detailed elements addressing the organizational structure and expected areas of action, but does not describe on-the- ground practice. This best-practice model for the transit envi- ronment used data collected from throughout the US and Canadian industry, a thorough reading of the research and practice literature, and expert guidance to adapt and refine these established models. The resulting 6 components, cov- ering 29 elements, represent a systematic model of effective transit workplace health protection and promotion practice, from getting started and building the team through evaluation and growth. This framework is illustrated in Figure 8, Transit Workplace Health Protection and Promotion Roadmap. Excellent WHPP practice in the transit industry is pos- sible, on a large and a smaller scale, as is shown through the case description and the 5 case studies described in Chapter 4: Case Examples and Case Studies. Although the case studies were each selected to illustrate good practice in a single tar- geted component of the Transit WHPP Best-Practice Frame- work, when rated for the 29 individual elements, the average overall scores were also high. These programs were rated high- est for the commitment of staff, using a team approach, and adapting and growing. Cases were on the average less strong in evaluation and return on investment calculations, and on some elements of implementation and integration that var- ied widely among all agencies in the survey population, such as labor support, involving vendors, and the integration of training and incentives. Table 27 lists the actions required to achieve the best-practice elements and the average ratings for the 5 best-practice cases. This transit-specific best practices model is comprehensive and even ambitious. Many organizations will not be prepared to fully execute all of the elements. Using the Practitioner’s Guide and the Planning, Evaluation, and ROI Template discussed in Chapter 6: Program Evaluation and Return on Investment, transit agencies and unions will be able to assess elements to decide which best practices are needed and how to fit them in to their WHPP program structures. How- ever, the outline is not designed to be adopted in a piece- meal fashion. Rather, an effective program, whatever its size or structure, needs to be tied together through planning, implementation, and evaluation. The model, as explained in detail in the Practitioner’s Guide, provides a structure for transit organizations wishing to start, expand, or improve a best-practice Workplace Health Protection and Promotion program, at a basic or enhanced level. The structure will help the organization take into consideration the likely effective- ness in their environment, the efficiency and feasibility of the practices given resources and health climate, and the spe- cific transit application and diversity, cultural relevance, and regional variation.

207 Figure 8. F-17 transit workplace health protection and promotion roadmap. Table 27. F-17 case studies: rating case studies for WHPP best-practice elements (1 5 not present or inadequate, 2 5 minimal or uneven, 3 5 adequate, 4 5 strong, 5 5 exemplary). WHPP Components and Elements Average Case Study Rating Average—All Components 4.11 Preparing the Organization and Making the Commitment 4.30 Culture of Health and Safety: The organization maintains a healthy and safe culture based on leadership and organizational commitment 4.40 Organizational Needs Assessment: The organization identifies workforce health status and needs, and understands the sources of health problems 4.20 Organizational Resources: Program planners identify resources including staffing, finances, programs, structures, and internal and external partners 4.20 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 4.40 Building the Workplace Health Protection and Promotion Team 4.14 Taking the Lead: The organization designates dedicated staff to coordinate and implement the workplace health protection and promotion program 5.00 Putting the Team Together: Input is gathered from across the organization 4.60 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 4.40 Labor Support: Union leadership and other representatives have influence on and support the workplace health protection and promotion goals and content 3.20 (continued on next page)

208 WHPP Components and Elements Average Case Study Rating Process Measures: The organization tracks costs, participation, goals met, and barriers then uses data to improve the program 4.40 Impact and Outcome Measures: The program documents changes in impact measures and outcome measures 3.80 Cost-Benefit and Return on Investment: Quantify cost savings when program affects absenteeism, productivity (presenteeism), health care utilization, and other costs, and document other benefits 2.60 Data-Driven Ongoing Improvement: The organization communicates the impact of the program 4.20 Maintaining Effectiveness with Growth 4.47 Maintaining: Workplace Health Protection and Promotion is essential to the organization, not an extra 4.40 Growing: The WHPP program adapts 4.80 A Realistic Perspective: The WHPP program prepares for difficulties 4.20 Implementing and Integrating an Effective Program 3.96 Comprehensive Range: The WHPP program offers varied activities and resources 4.20 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 4.00 Comprehensive Communications: Set up a strategic, comprehensive, and integrated communications plan with multiple communications pieces and delivery channels that are tailored to the transit population 4.00 Training Supports the Program: Training is designed to promote the program goals, not just deliver information, and is integrated into other agency training 3.80 Equitable Incentives: The organization utilizes equitable, nondiscriminatory incentives that encourage active involvement and a healthy workplace culture 3.80 Evaluation, Return on Investment, and Ongoing Improvement 3.70 Evaluation Framework: The organization establishes a comprehensive workplace health protection and promotion program evaluation plan 3.60 Integrated Data Management: Data collection, management, and analysis is coordinated throughout the organization 3.60 Committee: The organization sets up and supports a group to take action on workplace health protection and promotion 4.00 Champions and Ambassadors: Employee skills support and contribute to planning and implementation 4.20 Vendor Integration: The organization enlists health care providers and other vendors as partners in and contributors to the WHPP program assessment, planning, and implementation 3.60 Setting Targets 4.10 Setting Priorities: The organization establishes what matters and what can be done with available resources 4.20 A Comprehensive Health Risk Focus: The organization identifies and targets multiple contributing factors to operator health problems and conditions 4.00 Effective Components: The WHPP program activities are based on feasible and effective practices that address the identified program targets 4.20 Transit-Specific Implementation: The program planning and content address transit- specific risks, exposures, and conditions 4.00 Table 27. (Continued).

209 Program Evaluation and Return on Investment Background Evaluation and metrics are core elements in a system- atic approach to determine whether intended outcomes are achieved. Good metrics have proven value for assessing how well the programs meet their objectives, demonstrating accountability to funders and others who are in a position to make decisions about the future of a program, and leading to continuous improvement of the program. One research goal that distinguishes the F-17 project from previous studies on similar subjects is its emphasis on not simply program evalu- ation in general, but quantitative program evaluation that will eventually lead to the identification of unmeasured program costs and benefits measures and a rigorous return on invest- ment analysis. Using a 3-step research process including a broad industry survey, targeted case descriptions, and in-depth case studies, the F-17 research team examined methods cur- rently used by agencies to evaluate the success and calculate a return on investment of workplace health protection and pro- motion (WHPP) activities that have been implemented. Using this data, the Planning, Evaluation, and Return on Investment (ROI) template was developed to help transit agencies evalu- ate, track, and analyze their WHPP programs. Data collected for the F-17 project revealed that the transit industry increasingly realizes the value of consistent, objec- tive evaluation and analysis of benefits relative to costs and ROI. However, many transit organizations find it difficult to measure program performance in quantifiable terms, par- ticularly with regard to health promotion programs that can lead to a myriad of individual, group, and corporate impacts. Program staff are asked to justify their budgets, especially when faced with widespread transit fiscal crises and budget cuts. Unfortunately, too many transit professionals do not have answers to these important questions because they lack the tools and resources, and sometimes access to information, necessary to carry out these analyses. To help tackle this chal- lenge, the F-17 project team developed a series of practical tools and templates for planning, monitoring, and evaluating transit WHPP programs that will also help each transit orga- nization establish its own return on investment estimates. This chapter begins with a brief review of literature on the impact and ROI of WHPP within and outside of transit. The F-17 survey findings on the current practices of transit agen- cies and unions regarding program tracking, evaluation, and ROI analysis are then presented, with a comparative analysis by agency size. It is followed by a summary of program evalu- ation efforts from case study locations. The ensuing sections discuss issues and suggested solutions in an effort to improve transit organizations’ ability to carry out comprehensive eval- uations to support their WHPP programs. Literature The bottom line impact of workplace health promotion should be to improve employee health, control health care costs, increase operations efficiency, and decrease absentee- ism. A comprehensive workplace health protection and pro- motion program will identify and abate health hazards in the workplace and remove work organization impediments to a healthy lifestyle or healthful practices. These changes will help employees and the organization as a whole. WHPP programs have been shown to pay off. The need is felt by employers and workers: Increases in health premium costs (180%) and worker contributions to premiums (172%) outpaced overall inflation (38%) and workers’ earnings (47%) between 1999 and 2012 [Kaiser Family Foundation and Health Research and Educational Trust (HRET), 2012]. Employers are turning to health management initiatives to reduce health care costs. An actuarial study identified wellness programs as poten- tially affecting approximately 25 percent of health care costs for working populations (Bolnick, Millard, & Dugas, 2013). A combined analysis of the workplace health promotion lit- erature found that on average, reported medical costs fell by $3.27 for every dollar spent and absenteeism costs fall by C H A P T E R 6

210 $2.73 for every dollar spent (Baicker, Cutler, & Song, 2010). Table 28 illustrates the summary results of this study. A 2012 review of 20 publications on corporate wellness pro- grams found economic and health-related outcome improve- ments including: • Decreases in high blood pressure, high cholesterol, poor nutrition, obesity, physical inactivity, and tobacco use; • Health care direct costs either increasing less or decreas- ing over time (i.e., total health care costs, health insurance premiums, and workers’ compensation claims). The costs compared favorably to those of US employers, the general US population, and the health care industry; • Fewer absences and higher productivity; • Returns on investment ranging from 1.6 to 3.9 in dollars saved versus spent on the wellness programs. The net-cost estimates for 3 case studies targeting lower back pain show that ergonomic interventions applied appro- priately can result in substantial cost savings. Benefit-to-cost ratios for the case studies ranged from 5.5 to 84.9. In addition, a review of over 70 worksite wellness programs concluded that the economic return of worksite wellness programs show average annual ROI from 150 percent to almost 2,000 percent (Chapman, 2008). The average for more than a dozen tradi- tional worksite wellness programs is 300 percent (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, such as longer working tenure and improved availability. The abundant literature on the impact and returns of work- site wellness program investment has focused largely on office and health care employers. In transit and transit-related occu- pations recent quantitative documentation is limited. As the F-17 case studies showed in Chapter 4, Capital Metro in Austin is among the transit agencies reporting on the measured eco- nomic value of their WHPP programs. A study by the Centers for Disease Control and Prevention found that participants in Capital Metro’s wellness program reported improvements in physical activity, healthy food consumption, weight loss, and blood pressure (Davis et al., 2009). Capital Metro’s total health care costs increased by progressively smaller rates from 2003 to 2006 and then decreased from 2006 to 2007. Absenteeism decreased by approximately 25 percent since the implementa- tion of the program, and the overall return was calculated to be $2.43 for every dollar invested. In a 2009 study researchers assessed the economic impact of a hypertension educational and awareness program (“BP Downshift”) on improvement in blood pressure among com- mercial driver license (CDL) employees in a large southeastern US electric utility company (Greene et al., 2009). An economic simulation model was developed to evaluate the costs/cost savings the company realized from implementation of the BP DownShift Program in terms of changes in work productiv- ity, CDL certification status, hypertension treatment, CVD events, and diabetes care. Model results showed a 16.3 reduc- tion in costs for a sample of 499 CDL employees over 2 years for more than $540,000. On a per-employee basis, 2-year cost savings were estimated to be $1,084, or $542 annually. Research Findings In designing the industry survey, interviews of targeted survey respondents as well as the detailed case studies, F-17 researchers paid particular attention to extracting data on the current methods used by transit organizations to document quantifiable success and ROI. The combined research find- ings are presented below: Measures of Success Survey respondents rely on a wide range of data to evaluate program effectiveness. Between 40 and 60 percent say they track the effects of the WHPP programs using employee feed- back, program participation rate, time lost/absenteeism, and health care claims cost. When questioned for details many do not have a way to link this data to their practices. No evalua- tion data was reported by 20 percent and another 20 percent collected only one indicator. As illustrated in Table 29, the top 2 effect measures are related to participant satisfaction rather than health or opera- tions outcomes. This is common in informal program evalu- ation. As the WHPP programs are not typically designed to affect these health outcomes directly, the connection between the programs and the outcomes will need to be established. Study Focus Average Duration (years) Average Savings per Employee Average Costs per Employee Average ROI Health Care Costs 3 $358 $144 $3.27 Absenteeism 2 $294 $132 $2.73 Table 28. Cost-benefit and ROI analysis of 22 health promotion studies.

211 Several respondents noted that they could not be sure that their programs caused any observed health changes. Agencies participating in the case studies and other follow- up discussions reported using a wide variety of evaluation tools and have provided useful examples for the development of the Planning, Evaluation, and ROI Template in the second phase of the project. Several have described the use of health provider information indicating improved health care ser- vices usage and better health markers as major supports for their program planning and expansion. Return on Investment Calculations Only three agencies reported that they had calculated a return on investment in the past using their experience data. One reported a net loss, and another reported a $3 dollar return on every dollar spent. The future return on investment estimate, ranging from 0 (4 respondents) to $4 (2 respon- dents), was reported by 14 agencies. On average, respondents expect to recoup $2 for every dollar they spend on WHPP programs. Nine of the 22 respondents believe it will take at least three years to see a return. When asked about what their expected ROI is based on, respondents reported using health care claims, time lost/ absenteeism and workers’ compensation claims data (Table 30). Some described using health utilization or outcomes data pro- vided by their carriers. Evaluation Practices by Agency Size The extent of and approach to WHPP program evalua- tion varies largely by the size of transit organizations, as the F-17 survey data suggest. In Figures 9 and 10, the percent of responses to each measure for tracking program progress and outcomes are charted by agency size (defined by the number of vehicles operated). Across nearly all the measures, small agencies were less likely to use any of these measures than medium and large agencies. Health status is the only area where small agencies have a slightly higher percent (22 per- cent) of reported utilization than large agencies (21 percent), but both are lower than that of medium agencies (35 per- cent). Interestingly, in 5 out of 11 potential measures such as absenteeism, health care costs, and health status, medium- sized agencies outdid large agencies. Similarly, in answering the related question “What savings is your ROI based on?” small agencies came in lowest in 4 of the 6 potential savings areas, as shown in Figure 11. A higher proportion of medium- sized agencies used health care claims costs, disability costs, and absenteeism costs than among large agencies. In the follow-up interviews with survey respondents, small agency representatives described their difficulties with met- rics collection and analysis when the wellness program may be on the verge of shutting down due to budget concerns. Larger agencies may be in a better resource position to con- duct in-depth program evaluations. The F-17 survey and case studies did reveal that health-conscious medium-sized transit organizations can make a more significant investment in their evaluation effort, contributing to improvements in program design, advancing leadership support and employee engage- ment, and long-term financial stability and growth of the pro- gram. Indeed, the case study location that earned the highest overall score on program evaluation is medium in size. Issues and Suggestions Although employee wellness programs have been ongoing in some transit agencies for many years, agencies may be reluc- tant to introduce systematic program evaluation for many reasons. Throughout the research, the F-17 research team identified a set of important issues and concerns expressed by transit agencies and union representatives, as discussed N=45 Percent of Responses Employee Feedback 60.0 Program Participation Rates 51.1 Time Lost/Absenteeism 48.9 Health Care Claims Cost 46.7 Workers Compensation Claims Cost 42.2 Health Status 27.8 Behavior Change 26.7 Disability 17.8 Turnover Rates 15.6 Other 15.6 Employee Availability 8.9 Productivity 8.9 Table 29. F-17 survey respondents: tracking and measuring program success. Based On N Health Care Claims Cost 17 Time lost/absenteeism 17 Workers compensation claims cost 14 Disability 5 Productivity 5 Turnover (new hire recruitment/training) 5 Other 5 Table 30. F-17 survey respondents: ROI savings.

212 below. Additional solutions, resources, and tools that can help mitigate these concerns are provided in the Transit WHPP Practitioner’s Guide and the Planning, Evaluation, and ROI Template. Lack of Resources It can take a lot of staff time to expand from tracking simple process measures such as participation rates to include impact and outcomes metrics and eventually cost-benefit analysis. Increased investment in the agency’s IT and data infrastruc- ture may be required, for example, updating HR databases to link wellness-related modules, or implementing a web-based participant tracker. There may be additional vendor costs for administering health risk assessments or other evaluation tools. Many agencies, particularly small ones, do not have a designated WHPP staff or sufficient funding to evaluate work that is not considered part of the core program. However, robust evaluation results can help build a stronger case to present to internal leadership or external funding agencies Employee Feedback Program Parcipaon Time Lost / Absenteeism Health Care Claims Workers Compensa- on Health Status Large 50% 50% 32% 32% 36% 21% Medium 47% 47% 53% 53% 29% 35% Small 22% 4% 17% 13% 17% 22% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% % o f A ge nc ie s w ith P ro gr am s Figure 9. F-17 survey respondents: metrics tracked by agency size. Behavioral Change Disability Turnover Employee Availability Producvity Large 25% 18% 18% 4% 4% Medium 12% 18% 6% 24% 12% Small 13% 0% 4% 0% 4% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% % o f A ge nc ie s w ith P ro gr am s Figure 10. F-17 survey respondents: metrics tracked by agency size.

213 for maintaining and expanding the program. This data can also help win a stronger commitment from employees and their unions, establishing a virtuous cycle in the growth of the program. Data can also be used for adjusting program targets and phasing out program activities that do not produce an adequate impact. Silos Effect One of the most frequently mentioned problems in secur- ing evaluation data has to do with the silo effect, where func- tional areas within a transit agency are so isolated that sharing of information across divisions becomes time-consuming and frustrating if not impossible. Identifying and involv- ing internal partners early on and using an integrated data management system to break down the departmental bar- riers to data sharing are described in detail in the Transit WHPP Practitioner’s Guide. Some transit organizations have successfully utilized a cross-departmental WHPP committee structure for better communication and collaboration regard- ing data. It is important to understand the different perspec- tives that representatives from each department bring, and how the WHPP program may affect them. This sharing of interests will help integrate their ideas into evaluation activi- ties, and develop ways to keep all stakeholders informed of the evaluation progress and results. Evaluation as an Afterthought As in any type of program evaluation, the importance of establishing a baseline for analysis cannot be stressed enough. However, it is often overlooked by those carrying out the pro- grams, who may engage in activities then try to reconstruct the data needed for assessment. The Planning, Evaluation, and ROI Template is designed to assist practitioners with lay- ing a solid foundation for evaluation at the beginning of their programs. Data Confidentiality Confidentiality was a major concern for workers as poten- tial participants and for the unions representing them. F-17 respondents reported reluctance to participate in health risk assessments or share personal health data, particularly for health issues that can lead to medical disqualification of opera- tors. This lack of trust needs to be acknowledged and addressed systematically. In terms of the program, HIPAA confidential- ity requirements must of course be rigorously observed. At the same time, most aspects of WHPP should not rely on collecting individual health data. Some agencies described in the case studies do not use an HRA process because the aggregated, deidentified data provided by the health plan is more useful and less controversial. The Practitioner’s Guide provides several approaches to ensure confidentiality in data collection and evaluation results sharing. Lack of Identifiable Savings in the Short Term The implementation of a comprehensive health and well- ness program may well be associated with a cost increase in the first year or 2. It is therefore important to take a long-term perspective when implementing such programs and evaluat- ing their effectiveness. For example, epidemiological evidence about smoking suggests that preventing smoking and helping people quit smoking would decrease heart disease and cancer, Health Care Claims Cost Workers Compensaon Cost Disability Time Lost /Absenteeism Producvity Turnover Large 21% 25% 11% 25% 7% 14% Medium 35% 24% 12% 35% 6% 6% Small 22% 13% 0% 17% 9% 0% 0% 5% 10% 15% 20% 25% 30% 35% 40% p er ce nt o f A ge nc ie s w ith P ro gr am s Figure 11. F-17 survey respondents: ROI savings by agency size.

214 resulting in lower health care costs. But the cancer and some of the heart disease costs savings are so far into the future that it is difficult to determine accurately how much would be saved, and it is impossible to use health savings to show program efficacy in a timely way. In the Planning, Evalua- tion and ROI Template, the team has focused on the most practical measures that transit practitioners may collect in a reasonable time period—between 1 to 5 years. Difficulty Measuring Productivity Presenteeism—reduced productivity resulting from less than optimal health—is difficult to measure in the world of transit operations. It ranks the lowest among all the measures agencies track in terms of program outcomes. However, given appropriate tools, documenting the productivity gains from WHPP programs can be within reach of many transit prac- titioners. The Practitioner’s Guide describes the methodol- ogy and examples of survey instruments that can be used to measure presenteeism and estimate the associated financial benefits. Impact on Retention A high level of bus operator turnover may be one of the big- gest workforce challenges transit organizations face. The cost of turnover can be high, as transit bus operators is also one of the most difficult titles to recruit to because of rigid sched- ules and little flexibility, according to TRB Special Report 275: The Workforce Challenge (2003). The F-17 project set out with the hypothesis that initiatives focusing on operator health and stress would be in place to address retention rates. How- ever, most survey respondents and case study interviewees do not see a direct connection between WHPP initiatives and operator retention. In the survey, turnover is among the least frequently used measures of success for transit WHPP programs, and savings from reduced turnover ranked last in respondents’ consideration of an expected ROI, even though turnover data is usually readily available. Transit practitioners feel that their programs are, for the most part, not capable of effecting changes in the most undesirable aspects of an opera- tor’s work, such as schedules and customer encounters, which can lead to voluntary turnovers. On the other hand, initiatives such as targeted training and supporting mechanisms prior to CDL renewal can help reduce involuntary terminations caused by medical disqualifications. Difficulty Isolating Effects Even the most rigorous scientific research may not be able to isolate the effects of the WHPP program relative to other changes in complex, real-world environments. This is a recog- nized deficiency in the few existing cost-benefit studies per- formed by transit organizations. At the same time, without investing a large amount of resources, transit WHPP prac- titioners can make an informed estimate of 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 pro- gram participants. The Planning, Evaluation and ROI Tem- plate allows users to provide estimates of savings from WHPP programs alongside the total identified savings and calcula- tion of an ROI range rather than a single rate. Conclusion Systematic evaluation can help transit organizations assess whether the program implemented has resulted in desired changes, goals, and objectives being achieved, or whether there has been progress toward meeting such goals. Data from the evaluation process contributes to decision making about future targets and resource allocation. Data can also point to barriers, opportunities, and mid-course corrections needed to meet goals, leading to the process of continual improvement. Although return on investment is not the only reason to implement WHPP, in many transit workplaces the absence of a documented positive return makes it hard to justify pro- gram costs. The Practitioner’s Guide provides best-practice guidelines for planning, designing, and implementing WHPP program evaluation, and the complementary Planning, Eval- uation, and ROI Template offers a rich collection of tools to track and analyze program costs and direct and indirect benefits based on improvements in health status, productiv- ity, availability and safety, as well as reductions in absentee- ism, turnover, and health insurance costs, and produces ROI estimates.

215 Toward a Transit-Specific Program Answering the Initial Questions— A Summary of Transit Agency and Union Survey Responses The initial F-17 research proposal asked about 22 areas rele- vant to bus operator workplace health protection and promo- tion. They covered responding transit agency characteristics, WHPP program structure and targets, evaluation, program integration and partners, and transit-specific and operations concerns. This chapter summarizes transit agencies’ and unions’ responses to those questions, discusses some of the project’s new findings and the work products, and describes a practical application model for transit workplace health pro- tection and promotion. Transit Agency Characteristics Of the 238 transit locations with scheduled bus service invited to participate in the survey, 67 agencies and 40 unions responded, for a total of 93 distinct employers. Active agency health promotion programs were reported by 45 transit agen- cies and 15 unions, in 52 transit locations. Five unions ran sep- arate union programs. Responses came about equally from the Midwest, Northeast, and South, with a larger proportion from Canada and the US West. Large transit agencies were slightly overrepresented in the responses. The workforce is predomi- nantly older and male, although in some agencies women and younger workers are strongly represented. The workforce is ethnically diverse. In most agencies all employees work full-time. WHPP Program Structure and Targets Programs were started mainly to address work-related injury and illness (80 percent), availability (68.3 percent), and health care and workers compensation costs (both 62 per- cent). The top health problems reported were chronic disease and musculoskeletal problems; about half were concerned with achieving desired physical activity, diet, or tobacco use and with responses to work demands and work-family con- flict, such as fatigue or stress. The order varied somewhat between management and unions but the differences were not statistically significant. The 3 top program targets in the preceding 12 months were nutrition, weight management, and stress management. Educational messages, educational classes and events, health screenings, and counseling were provided in most of the transit agencies with programs. About half of agencies reported activities targeting nutrition, policies that support a healthy environment, support for alternative health, onsite exercise facilities or programs, and occupational health and safety. Activities ranged widely across individual, group, and organizational targets, from weight loss programs to subsi- dized treatment for CDL-related health problems to ergo- nomics assessments leading to procurement changes. They included social concerns such as charity fundraising and financial wellness. Participation was higher in required and passive promo- tion efforts such as mailers; classes were reported to reach everyone, while the potentially more effective initiatives such as gyms and HRAs with counseling were not reaching more than 20 percent of bus operators in most organizations. Low participation was attributed to schedule conflict and lack of interest. Communication most commonly reported included hand- outs, mailers, email, and electronic bulletin boards. While some agencies tailored the materials to the bus operators, most used generic prepared materials. All agreed that transit- specific communication and education is badly needed. Few evaluated the reach or effectiveness of communications. Reported budgets ranged from $0 to more than $300,000 a year. Formal business or strategic plans were described by the transit agencies with budgeted staff and extensive program activities, but in many others planning was not formalized. C H A P T E R 7

216 Most agencies used some type of incentive to encourage par- ticipation in the WHPP program. Individual prizes and cash or gift cards were most common, followed by group rewards. Insurance-related incentives were rare. Program Evaluation Formal evaluation is not the norm, with employee feed- back the most common measure of program effectiveness collected, followed by program participation rates, time lost, health care claims cost, and workers compensation claims costs. Turnover rates, employee availability, and productivity measures were not frequently analyzed by the WHPP pro- grams. Only three agencies reported calculating the return on investment for their WHPP programs. Of the 14 who pro- vided estimates of future returns, many anticipate a benefit in the near term, but almost half would expect 36 or more months to see a positive return. Program Integration and Partners Transit agency contacts felt that their WHPP programs were well integrated with operational administrative policies and procedures and areas such as safety or benefits. The union respondents were about half as likely to agree that the WHPP program was well integrated. Many transit agency and union respondents felt that information and decision making often took place in silos of influence, limiting effectiveness. Specific WHPP program activity frequently overlapped with worker health protection and related concerns such as ergonomics. Following the survey process, many respondents spoke about planning to integrate their activities to improve effectiveness. Both transit agency and labor contacts felt that their own organizations supported the program and made it a top pri- ority, with less confidence in the other side of the table: most of the agency responders agreed that upper management provided such support, as did less than half of the unions. In parallel, the majority of union survey respondents felt that union leadership supports and participates in the program, while less than half of agency respondents agreed that they did. The role of the unions in WHPP included none, general support for management initiatives, an active role in the tran- sit agency including participating in committees and plan- ning, purchasing equipment, and running an independent program. Agency and union respondents reported the health plan as the number one external partner to their WHPP program. Other resources and allies may be underutilized. Several pro- grams made extensive use of local and national resources, including participating in CDC initiatives, and working with universities to implement or evaluate their programs. No US state and local governmental mandates for health and wellness programs were identified. Canadian health reg- ulations were cited, along with APSAM, the Quebec Joint Association for Health and Safety at Work, Municipal Sector. Transit-Specific and Operations Concerns Few agency survey respondents reported that route sched- ules have an impact on operator health problems or identified scheduling as an area that the WHPP program has affected. In contrast, the majority of union respondents believe that schedules have an impact on the identified health problems of concern. However, in open-ended survey questions and interviews, most respondents recognized that route schedules and tours could have an impact, and reported that schedules were adjusted to allow for rest, eating, and restroom use. All respondents acknowledged that the costs and other challenges of adapted service schedules to improve operator health pre- sented a significant barrier. Survey and interview contacts described a wide range of organizational polices and conditions that affect bus operator health, agency costs, and availability. While respondents were aware of supportive polices in related areas such as leave time, ergonomics, and a health-promoting environment, effective ways for influencing those policies were limited by their separa- tion from other departments. Almost all cited the organization of operators’ work, including schedule pressures and working alone, as a significant barrier both to program effectiveness and health improvement overall. The impact of work organi- zation and conditions on health was addressed in most agen- cies, sometimes in coordination with the WHPP program and staff and sometimes independently, including return to work accommodations, assault, or customer conflict prevention program and workplace health and safety inspections, and other programs. Absenteeism is the top health impact of concern identi- fied by most transit agencies, but few WHPP programs were described in the survey as having an impact in this area. Only one-third characterized medical disqualification as an impor- tant result of bus operator health problems. Survey respon- dents do not see a strong connection between the identified operator health problems and turnover, and few reported concern about availability on the survey. Again, the issue was recognized more fully in discussions and interviews. Research Highlights Important Targets for Transit Agencies Among the most significant finding of the F-17 research project was the demand for transit-specific health informa- tion and activities needed to address the connections seen

217 between worker health and the work organization and envi- ronment. The other recurring issue was the importance of trust and collaboration in workplace health protection and promotion. Transit agencies did not always make the connec- tions in their initial survey responses. The reality surfaced, to the research team and to the transit agency WHPP staff and other team members, in the examples they provided of what they do, what works, and where they feel they fall short. Con- trary to expectations, retention was not a major concern of WHPP program staff and supporters. Transit-Specific Resources The single most consistent need described by F-17 survey and interview contacts was for content and approaches that made sense in the transit workplace, specifically for transit bus operators. This could include new ways of using well-known activities, as well as innovations in practice and perspective. While requesting these resources, respondents generated scores of examples of their own, which are listed in Appen- dix B. The Transit WHPP Practitioner’s Guide is designed to make those widely available. Many respondents also wanted to establish ongoing ways to communicate among those active in transit WHPP. The subject-matter expert group convened for this project would like to keep meeting by phone. Unions have expressed an interest in setting up their own programs using the network of support developed here, and transit agency staff and employees plan to keep sharing what they do. Retention Is Not at the Top of the List of Health Promotion Targets A core assumption of the initial research was that the costs related to retention problems, and especially the concerns about the imminent dearth of skilled operators, would drive workplace health promotion practice. Retention and turnover were not widely considered to be linked to health problems, according to survey and interview contacts, but seemed more related to better pre-hire procedures. However, as some respon- dents pointed out, if the reasons for separation are not evalu- ated carefully, the impact of health cannot be determined. An early study of Dutch transit workers suggested that 45 percent of all transit workers left the industry because of health prob- lems and disability by the time of retirement, and bus opera- tors believe unreported work-related pain and ill health are a major cause of turnover (Mulders, Meijman, O’Hanlon, & Mulder, 1982). This area requires further investigation, includ- ing the use of exit interviews as well as earlier organizational support for mental and physical health concerns as described by some human resources respondents and others. Medical disqualification related to diseases that can be con- trolled or prevented is an acknowledged concern. Several agencies provide additional support or incentives to help operators achieve a complete certification. They do this in part to eliminate the additional cost and lost time incurred when operators are under provisional licenses. At the same time, CDL status is a strong motivator for health improvement, so targeting these employees is an efficient use of resources. Trust and Collaboration Are Core Yet Underdeveloped Components of WHPP Agency and union respondents reported that bus opera- tors frequently did not trust or welcome health promotion initiatives. Participation in health activities was limited. This was true even in areas that unions supported such as work- site exercise facilities, which could be related to scheduling demands and other work conflicts, as well as to the well-known and universal difficulty health promoters have in helping people to increase their physical activity. It was especially true in program elements that could be seen as intrusive or puni- tive, such as health risk assessments or insurance premium incentives. Because of this, union leadership and the union structure remain underutilized, and unions do not have the control and influence that could produce health benefits for their members. The WHPP program staff and the top transit agency exec- utives were uniformly positive about their health promo- tion approach. However, bus operators often see a tough and stressful work environment that contributes to health prob- lems and a health promotion program that focuses on indi- vidual lifestyle. Too often employers perceive a workforce that seems to care little about the challenges that their own health presents to effective operations, service provision, and fiscal survival of the organization. When the demands of work on health are honestly appraised and addressed, it is more feasi- ble to establish a health-promoting environment and provide program components and activities that suit the needs of the workforce and the workplace. The most successful programs identified in the F-17 research process were notable for the degree of support demonstrated by both labor and transit agency staff. In these organizations, bus operators were active contributors to the planning process as well as consumers of the services. In one the health and safety issues were at least as significant as the individual program activities. In most of the cases the role of work organization was recognized and attempts were made to reduce the health impact. A Practical Application of WHPP Models In traditional health promotion, the workplace can func- tion as a convenient place to get access to individuals rather than an integral component in the human health equation.

218 Workers have health problems, which they need to have diag- nosed and treated. The health problems may result from fac- tors 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 comprehensive WHPP model recognizes that the environment—what the working conditions are, and how the organization functions—also affects health. WHPP programs in transit agencies that work with their partners to define and recognize the variety of contributors to health problems are in a better position to correct or control them. 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). So addressing concerns about asbestos or diesel exposure at the same time as providing support for quitting smoking repre- sents a coherent approach to health protection and promo- tion that is more likely to be trusted and more likely to lead to health improvements. The practical application of workplace health protection and promotion is laid out in detail in the Transit WHPP Prac- titioner’s Guide. It provides a framework to ask and answer the important questions about transit worker health. Fig- ure 12 illustrates the application of the approach to metabolic syndrome in transit work. For successful development and implementation of a com- prehensive WHPP, the same questions need to be asked about the organization: What is the current status of the work- place and the program? Is there trust? Is confidentiality a given? Are resources limited? Is communication a problem? Then, what do people do in the program? How are all parties involved in planning and integration of the program’s vision? Do workers participate in program activities, and, if not, why not? And finally, how does the environment contribute? For the program, that could be the challenging conditions of work that make planning harder and have to be taken into account. Hours of service and a mobile workforce are just two of many characteristics that have an effect on program success and that influence the goals the program can achieve. The Tools Transit Workplace Health Protection and Promotion Practitioner’s (WHPP) Guide The Transit WHPP Practitioner’s Guide that is Part I of this report is designed for anyone involved in 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, or a safety professional trying to introduce a new approach. The ideal WHPP leadership team brings all of those together. Its purpose is to help initiate, design, implement, evaluate, and maintain a comprehensive workplace health protection and promotion program that improves the health and safety cul- ture and the policies and practices that affect health in transit agencies. The 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 Sys- tem for Worker Health and the World Health Organization Healthy Workplace Framework and Model. Although most current programs in the transit industry focus on individual health issues and self-identify as wellness or health promo- tion, the growing consensus among research, government, and public health practitioners is that the best-practice work- place program is properly defined as encompassing 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 of the Practitioner’s Guide. Most significantly, the approaches described here and in the Practitioner’s Guide rely on the practical examples pro- vided 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. Figure 12. Metabolic syndrome in transit work.

219 Planning, Evaluation, and Return on Investment (ROI) Template As a complementary tool to the Practitioner’s Guide, the Planning, Evaluation, and ROI template was developed to help transit organizations with program planning, tracking of program process, impact and outcomes measures, and cal- culation of ROI for their health and wellness programs. The Planning, Evaluation, and ROI Template offers a rich collection of tools to track and analyze program costs and direct and indirect benefits based on improvements in health status, productivity, availability, and safety, as well as reduc- tions in absenteeism, turnover, and health insurance costs, leading to ROI estimates. The template includes instructions, user entries, and auto- matically calculated outputs in an easy-to-navigate spreadsheet. Sample data is provided so users may learn about how the tem- plate works without deploying real data. Users can also custom- ize measures according to their organizational needs. Additional tools and resources are provided in the template with links to reference articles, survey questionnaires, and online calculators. The template offers a universal yet customizable approach to measuring the impact and ROI of WHPP programs in tran- sit. However, the eventual implementation of systematic eval- uation at each transit organization is largely dependent upon their willingness to invest the time and resources required for the tracking, analysis, and documentation, and their ability to break down barriers with regard to data sharing and continu- ity of operations. Conclusion “The biggest barrier is the nature of their work, their job design. As bus operators, they work on their own and are mobile rather than working in a specific location during their work day. It is dif- ficult for them to attend training, workshops and events, etc. This is true in all aspects of their work, not just as it relates to health promotion/wellness initiatives.” Management representative The conditions of transit work have been shown to con- tribute to health problems. At the same time, transit work- ers, like anyone else, have serious health concerns that are influenced by their behavior, past exposures, and other fac- tors that may or may not be under their control. The condi- tions of bus transit work can make it harder to achieve health goals. As described by transit employees, from hourly to top management; by health professionals including safety, health promotion, and health care; by union representatives; and by government agency personnel, health concerns may be both common to most people and specific to transit. The consis- tent report is that people working in transit recognize there are problems. They want to do something about the prob- lems to keep workers healthier, transit agencies more suc- cessful, and the public moving. The way to do that is to pool resources within transit agencies and across the industry to improve the individual, organizational, and environmental conditions and risk factors that affect health. “We are combining programs to try to increase information and practice of healthy living. We have a Wellness Committee that brings forward programs and information. [We have a] ded- icated ergonomist that helps with drivers with specific problems and the Health and Safety Committee which seeks to remove hazardous working conditions.” Union leader Trust is key. The finding that both labor and management felt they supported the aims and intentions of the WHPP program but each undervalued the commitment of the other party remained a consistent theme in follow-up interviews. It represents a critical target for improvement across the indus- try. The health, safety, and wellness of bus operators and other transit employees are a recognized priority for all parties, but an acceptable model for cooperation has not yet been estab- lished in many locations. Among the most successful transit agencies investigated in the case studies, trust, respect, and commitment were expressed from all parties.

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224 List of Abbreviations AHRF Assessment of Health Risks with Feedback ATU Amalgamated Transit Union CDC Centers for Disease Control and Prevention CDL commercial driver’s license CUTA Canadian Urban Transit Association CVD cardiovascular disease DART Dallas Area Rapid Transit EAP Employee Assistance Program ENWHP European Network for Workplace Health Promotion ETS Edmonton Transit System FMLA Family Medical Leave Act HR Human Resources HRA health risk assessment HRET Health Research and Educational Trust HSEC Health, Safety and Environmental Compliance HT hypertension IT Information Technology LACMTA Los Angeles County Metropolitan Transportation Authority MSD musculoskeletal disorder NIOSH National Institute for Occupational Safety and Health NRT nicotine replacement therapy OCTA Orange County Transportation Authority OH&S occupational health and safety OSA obstructive sleep apnea OSHA Occupational Safety and Health Administration PIR Partnerships in Injury Reduction PMR proportionate mortality ratio PTSD post-traumatic stress disorder RE-AIM Reach, Effectiveness, Adoption, Implementation and Maintenance RFP request for proposal ROI return on investment SHR standardized hospitalization ratio SME subject-matter expert TWH Total Worker Health™

225 US United States UTU United Transportation Union VOMS vehicles operated in annual maximum service WCB Workers’ Compensation Board WHPP workplace health protection and promotion

A-1 Roadmap and Best Practices for Transit Workplace Health Protection and Promotion A P P E N D I X A

A-2 Transportation Cooperative Research Program F-17 devel- oped a framework of six action areas for transit workplace health protection and promotion (WHPP), based on infor- mation collection from stakeholders, a literature review and analysis by subject-matter experts. The action areas corre- spond to the chapters in the Transit Workplace Health Pro- tection and Promotion Practitioner’s Guide. In this summary and the detailed Practitioner’s Guide, the best-practice ele- ments making up each action area are supported by concepts and steps to take to develop an effective, comprehensive and inclusive WHPP program. Getting Started: Preparation and Commitment Culture of Health and Safety Best Practice 1. 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 Best Practice 2. 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 Best Practice 3. Program planners identify resources includ- ing staffing, finances, programs, structures, and internal and external partners. • Are there qualified and motivated staff ? • What resources are found in the work environment? Transit Workplace Health Protection and Promotion Roadmap

A-3 as evidenced by documented communications, infrastruc- tural 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, bud- gets, availability, management models. • Communicate support throughout the organization. Labor Support Best Practice 8. Union leadership and other representa- tives 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 desig- nees or volunteers. WHPP Committee Best Practice 9. The organization sets up and supports a group to take action on workplace health protection and promotion. • Communicate with the occupational safety and health committee. • Identify and recruit WHPP committee members from man- agement and labor, including operations, HR, procurement, and OSH. • Observe protocols for joint committees. • Add location committees to meet more frequently. • Establish a regular meeting schedule that works for all. • Plan ahead to make meetings effective. Champions and Ambassadors Best Practice 10. Employee skills support and contribute to planning and implementation. • Identify management and operator champions and ambas- sadors 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. • 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 Best Practice 4. The organization develops a plan to pro- vide effective health assessments, a healthy and safe envi- ronment, 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. Building the Team: Coordinating Health Protection and Promotion Taking the Lead Best Practice 5. The organization designates dedicated staff to coordinate and implement the workplace health pro- tection 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 Best Practice 6. Input is gathered from across the orga nization. • 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 Best Practice 7. Senior and mid-level management sup- port workplace health protection and promotion initiatives

A-4 • Provide champions and ambassadors with schedule flexibility. • Sustain champion and ambassador role. Vendor Integration Best Practice 11. The organization enlists health care providers and other vendors as partners in and contribu- tors to the WHPP program assessment, planning, and implementation. • Find out what data is available and ask for data that you need. • Educate vendors and providers about the workforce and transit work demands. • Involve vendors in planning, evaluation, and implementa- tion: Promote use of vendor programs. • Enlist vendor support for health fairs. Setting Targets: Effective Transit Health Protection and Promotion Setting Priorities Best Practice 12. 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 Best Practice 13. 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 Best Practice 14. 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 work- place health protection and promotion. Transit-Specific Implementation Best Practice 15. 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. Implementing and Integrating: Balanced Workplace Health Protection and Promotion Inclusive Range Best Practice 16. The WHPP program offers varied activi- ties 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 activ- ities with the overall program. • Understand what occupational safety and health (OSH) and other issues are important: Involve families. Transit-Specific Implementation Best Practice 17. 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 sched- ules, 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, reporting. • Protect workers’ health information. Effective Communications Best Practice 18. Set up a strategic, comprehensive, and integrated communications plan with multiple communica- tions pieces and delivery channels that are tailored to the transit population.

A-5 • Keep the whole organization informed. • Assess the impact of the communication modes you use. • Recognize the value and limitations of electronic com - mu nications. • Provide online education and reporting systems that are accessible out of work. • Facilitate safe and confidential use of computer stations. • Engage recipients with written materials. • Keep leadership informed about program progress and impact. • Establish 2-way communication. Training Supports the Program Best Practice 19. Training is designed to promote the pro- gram 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 Best Practice 20. The organization utilizes equitable, non- discriminatory incentives that encourage active involvement and a healthy workplace culture. • Aim incentives at desirable and feasible targets. • Reward positive steps rather than punishing the current health status or health problems. • Analyze the incentives for the effect of schedule, family demands, other potential inequities, and take work chal- lenges 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. Evaluating: Return on Investment and Ongoing Improvement Evaluation Framework Best Practice 21. The organization establishes a compre- hensive workplace health protection and promotion program evaluation plan. • Collecting baseline measures. • Involve stakeholders in evaluation. Integrated Data Management Best Practice 22. 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 Best Practice 23. The organization tracks costs, partici- pation, goals met, and barriers then uses data to improve the program. • Record quantitative and descriptive data. • Use process evaluation to make time-sensitive adjustments. Impact and Outcome Measures Best Practice 24. The program documents changes in impact measures in 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, disability. Cost-Benefit and Return on Investment Best Practice 25. 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 achiev- ing a positive ROI. • Estimate the effect of the WHPP program.

A-6 Data-Driven Ongoing Improvement Best Practice 26. The organization communicates the impact of the program. • Package your evaluation data. • Communicate progress and success. • Present aggregated evaluation results to all levels of man- agement and employees. Carrying on: Maintaining Effectiveness with Growth Maintaining Best Practice 27. Workplace Health Protection and Promo- tion 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 Best Practice 28. 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 Best Practice 29. The WHPP program prepares for difficulties. • Looking for problems means you find them. • You can’t solve everything.

B-1 Supplementary Tables B-1 B1 Responses by State and Province B-2 B2 Detailed Titles of F-17 Survey Respondents B-2 B3 Plans and Suggestions for More Effective Programs A P P E N D I X B AB 2 AK 3 AZ 2 BC 2 CA 15 CO 1 CT 2 DE 1 FL 2 GA 2 HI 1 IA 2 ID 1 IL 2 IN 3 KS 2 KY 2 MA 3 MB 2 MD 1 ME 2 MN 2 MO 2 MS 1 MT 2 NC 3 NE 1 NJ 2 NS 1 NY 3 OH 2 OK 1 ON 10 PA 2 QC 4 RI 1 SD 1 SK 1 TN 1 TX 3 UT 2 VA 1 VT 1 WA 5 WI 2 B1. Responses by state and province.

B-2 B3. Plans and suggestions for more effective programs. Assessment Collect greater data to measure program progress and potential ROI Assessment Develop methods for tracking ROI Assessment Introduction of metrics so as to assess returns on investment Assessment Metrics and ROI Assessment Regular feedback surveys that generate improvements in employee health Assessment The agency needs to have better measuring metrics in place in order to determine if any of the policies and practices have made a significant and positive impact. Metrics would also help us to determine how to spend the limited funding available for healthy policies and programs that do make an impact Assessment Tracking results Assessment With buy-in from senior management, conduct a health risk assessment of the organization’s strategic plan Assessment We would like to see our healthcare provider implement the personal risk assessment program again using the lessons learned from the prior attempt Administrator Department Administrator Department Head Director Director/Bus Transportation Director of Admin/Finance Director of Administration Director of Bus Operations (2) Director of Human Resources/ Risk Management Director of Occupational Health Services Director of Operations (2) Director of Transit Operations Director of Transportation Employee Wellness Manager Executive Director General Manager (2) Health and Safety Superintendent Healthy Workplace Specialist HR Assistant/Benefit Coordinator HR Supervisor Human Resources Director (4) Human Resources Manager (3) Human Resources/ Marketing Administrator Long-Range Planner Manager II, Health & Welfare Services Manager of Wellness & Rehabilitation Manager Operations Manager, Bus Operations (2) Mgr. Compensation and Benefits Operations Superintendent Operations/Customer Service Manager OSH and Benefits Corporate Advisor OSH and Health Promotion Corporate Advisor Payroll & Benefits Administrator QA Manager Registered nurse Risk Manager Safety & Training Coordinator Senior Human Resources Officer Sr. Health, Safety & Environmental Compliance Specialist/Wellness Administrator Team Leader - Non-Occupational Injury Team Trainer/Safety Officer Training Superintendent Transit Division Director Wellness Specialist Union President President/Business Agent Business Agent/Representative Co-chair Joint Health and Safety Committee Field Representative Bus operator International Vice President Recording Secretary Wellness Manager (Union-run agency program) Manager, Employee / Labor Relations Medical Director B2. Detailed titles of F-17 survey respondents.

B-3 B3. (Continued). Healthy Environment Healthier environment Participation Continue to educate our employees and increase their participation in the wellness activities at their work sites Participation Encourage a higher participation ratio on all programs Participation Incorporate incentives into the health insurance program, such as discounts for participating in screenings, no tobacco use, etc.—we've talked about it, but haven't gotten there, yet Participation Increased participation, informal leaders Participation More participation from all employees Participation Need to develop incentives for employees to participate in Wellness Programs Participation Operator interest. Most just want to come and do their job and go home. Little interest in staying on site unless they are being paid Participation Put together a monetary incentive program with big wins for employees who make big strides toward improving their health Participation To have the buy-in from employees to make the necessary changes to incorporate into their lives instead of throwing money at them to do so Participation We have a tough time getting employees involved in any programs Participation We will seek out new strategies to engage employees to foster a culture of health and fitness Participation Wellness incentives that impact monthly premiums Policies Physical hiring requirements Policies Update Agency health policies Policies What could be done is to make health and fitness less voluntary for employees (e.g., require smokers to quit, require obese employees to enter a weight loss program, and other interventions to require healthy lifestyles) Resources A budget that will allow working with an outside vendor to provide all the resources Resources A dedicated wellness budget would prove beneficial Resources A wellness liaison at each location Resources Additional funding Resources Additional internal resources Resources An onsite medical clinic Resources Budgeted resources Resources Build a fitness center in the facility where our Coach Operators report to and check out from work Resources Commitment of resources by Senior Management Resources Dedicated staffing Resources Funding Resources Giving this program a higher profile, including dedicated resources Resources Increased budget Resources Increased federal/state funding Resources More funding Resources More space for onsite activities Resources Some additional staff would be useful Resources Staff dedicated to workplace health promotion program Resources Trained staff on site at fitness centers for certain hours Resources We are currently talking with a gym in the area and are hopeful employees will see the value of a gym membership Resources We could use more dollars dedicated to implementing programs (continued on next page)

B-4 Support/Integration We could use more leadership, promotion, and participation from our senior staff and board members Support/Integration Wider representation across organization on related committees Transit-specific information and practice We have been working with our healthcare provider to target the high-risk lifestyle behaviors. The have been able to provide us with programs from their program listing. However, these programs were not tailored to the unique characteristics of the transit employee. We would like to see the provider implement programs that “fit” our employee population Transit-specific information and practice We would like to be in touch with other transit companies Transit-specific information and practice We would like to receive a feedback of the present survey Resources We will be replacing the former wellness coordinator with a certified occupational health nurse who will manage both wellness and cases management Resources Wellness site/facility on site Structure We have a good working relationship with our health insurance providers, but I think that a proactive team approach combining our wellness program and their health offerings to precisely target specific issues could bring some good results e.g., blood pressure and diabetes and prescription adherence Structure Implement a means of communication to the employee and family regarding the impact of poor health choices by showing them how these choices influence attendance, the ability to perform their job safely, and workers compensation costs Structure Daily interaction Structure Establish a Corporate Committee and Ambassador Network Structure Greater expansion of municipal workplace health initiatives to include Transit Operators Structure Identified workplace lead Structure Programs designed to meet identified needs at times when Operators can attend Structure Would be useful to have healthy workplace committees Support/Integration Increased coordination with a dedicated line staff or manager taking the lead Support/Integration Increased support and participation by the Union and greater support by line managers who could encourage their employees to participate in the program and to embrace healthier lifestyles Support/Integration Involving Operators in a committee Support/Integration Management/union/employee participation-money/time Support/Integration More buy-in by the local union leadership, particularly impacting health plan design Support/Integration More union commitment Support/Integration Multi-year commitment to a measurable sustainable wellness program. We have a very robust occupational health and safety program but our wellness component is less so. Commitment to OH&S is legislated and as such receives sufficient resources. Wellness programming is more susceptible to budget availability Support/Integration Organization could play a more active role in both promotion and participation in the program. Currently, it exists only because the insurer offers it at no additional cost. There is no budget for employee health/wellness Support/Integration Support of union reps Support/Integration Union leadership promoting and supporting the program Support/Integration Upper management buy-in B3. (Continued).

C-1 TCRP F-17: Improving Transit Bus Operator Health, Wellness, and Retention— Management Survey A P P E N D I X C

C-2 Improving Transit Bus Operator Health, Wellness, and Retention— Management Survey Welcome to the TCRP F-17 Improving Transit Bus Operator Health, Wellness, and Retention survey. Your input is very important to the success of this project. Once you have collected your background information, it should take you about half an hour to complete the survey. At any point you can save your answers. A special link will then be emailed to you so you can return later to your saved survey. This is allows you to collect and enter information at your convenience. When you have finished all the sections you click submit and the data is sent to us. Don’t worry if you don’t have all the answers. You may need to estimate, and for some questions you will not have information. We are interested in all aspects of your health and wellness activities - successful programs, the barriers you faced and even the failures. The important thing is to fill in what you can. If you are unable to do the survey for any reason, please let us know that. We hope to hear from you, and to learn from the important insight you provide. If you want to fill this out by hand, we can provide you with a hard copy. Our commitment to you: All information gathered in this survey will remain confidential and only grouped data will be shared or published. If you provide your contact information at the end of the survey, project researchers may follow up with you to get some more detailed information later in the project. Robin Gillespie, Senior Program Director for Health and Safety Transportation Learning Center rgillespie@transportcenter.org Phone: (240) 230-7065 Background 1) Transit agency name: ________________ ________________________________________ 2) Your title: ____________________________________________________________________ 3) What transit mode(s) does your agency operate? (Select all that apply) [ ] Fixed Route Buses [ ] Heavy Rail [ ] Light Rail [ ] Commuter Rail [ ] Paratransit [ ] Other, please specify): 4) What is the annual ridership in unlinked passenger trips of your fixed route bus service? [ ] More than 20 million [ ] More than 4 million and less than 20 million [ ] Fewer than 4 million

C-3 5) How many bus operators: Work here Work full-time Work part-time Are contracted independently or via a contract employer Are female Are under 40 Are Hispanic/Latin American Are White/Caucasian Are Black/African American Are Asian/Pacific Islander Are American Indian or Alaskan native Are other or multiple races Background 6) Are the bus operators represented by a union? [ ] Yes [ ] No 7) To help us understand the organizational structure of your workplace, can you estimate what percentage of the bus operators are dues-paying members of the union? [ ] 0% [ ] 1-25% [ ] 26-50% [ ] 51-75% [ ] 76-100% 8) What is the approximate average years of service of the bus operators? ___________ Health, Wellness and Safety Concerns 9) What are the top three health problems faced by bus operators at your agency? [ ] Chronic diseases (hypertension, diabetes, cardiovascular disease, lung disease, reflux and intestinal symptoms) [ ] Achieving desired physical activity, diet, and/or tobacco use status [ ] Wellness (such as stress and fatigue) [ ] Musculoskeletal problems (back injury, tendonitis, other pain) [ ] Work environment (accidents, work-related injuries or illnesses, assaults) [ ] Other (please specify):

C-4 Health, Wellness and Safety Concerns 10) Have these health problems affected or led to any of the following? (Select all that apply) [ ] Increased health care costs for the agency [ ] Work-related injury or illness [ ] Excessive absenteeism, sick leave, or disability [ ] Medical disqualification for operators [ ] Loss of employment due to disability or illness [ ] Turnover/retention problems [ ] Operational problems/delays [ ] Decreased workplace morale [ ] Other (please specify): 11) How much impact do the following conditions of your workplace have on the health problems listed above? None Some A lot ] [ ] [ ] [Route schedules Contact with riding public [ ] [ ] [ ] ] [ ] [ ] [ krow fo sruoH ] [ ] [ ] [ odof ot sseccA ] [ ] [ ] [ ssecca moorhtaB Occupational safety or health [ ] [ ] [ ] conditions Labor/management interaction [ ] [ ] [ ] Other conditions (describe): [ ] [ ] [ ] Other conditions (describe): [ ] [ ] [ ] Other conditions (describe): [ ] [ ] [ ] Worksite Health Promotion (WHP) Program 12) Does your agency have a WHP program or carry out health promotion activities that cover bus operators? (Choose 1) [ ] Yes, active [ ] Had in the past but no longer active [ ] Not currently active but plan to restart [ ] Not yet, but plan to have in the future [ ] No to all of the above

C-5 13) If you do not have a program or it is not currently active, can you say why? [ ] Not needed [ ] Needed but no funds [ ] Needed but no staff resources [ ] Other, (please specify) If you do not have a WHP program and do not plan to start one, your work on this survey is done. Please fax, email or mail it (information on the last page) with any comments or questions. Otherwise, please continue. 14) Describe the worksite health promotion programs or activities scope. [ ] Bus operators only [ ] All bus division staff [ ] Bus division along with other mode or division staff within the agency [ ] Municipal, multiagency, or other coordinated program or campaign (including bus operators) 15) Are or were family members involved in the worksite health and wellness program? [ ] Yes [ ] No If yes, please describe: Worksite Health Promotion Program 16) How many years has your WHP program been active (or was it active)? ___________ 17) Please state the approximate annual budget for your WHP program or activities. Then break out the components if you can. $Total $Staff $Outreach (newsletters, advertising) $HRAs/screenings $Training/workshops for workers $ $ Participation incentives Workplace changes (such as exercise facilities, food access, repairs) $Payments to outside vendors for activities or products $ rehtO

C-6 18) For those planning a program, what will be the target of your WHP program? [ ] Chronic diseases (hypertension, diabetes, cardiovascular disease, lung disease, reflux and intestinal symptoms) [ ] Achieving desired physical activity, diet and/or tobacco use status [ ] Wellness (such as stress and fatigue) [ ] Musculosketal problems (back injury, tendonitis, other pain) [ ] Work environment (accidents, work related injuries or illnesses, assaults) [ ] Other (please specify): ` 19) If not currently active, when is your target date to begin or restart a WHP program? _______________________________________________ WHP Program Environment 20) What health, safety, and wellness activity does your agency carry out? (even if you do not yet have a formal program)? (Select all that apply). Activity As part of a WHP program As part of other program ] [ ] [ stnemssessa ksir htlaeH Health screenings (blood pressure/blood sugar/neck [ ] [ ] circumference/lipids/weight) ] [ ] [Counseling/coaching Support for alternative health (for example yoga, massage) [ ] [ ] ] [ ] [Educational messages and information ] [ ] [Educational classes and events Policies that support a healthy environment (such as restricted [ ] [ ] tobacco at work or alcohol at events) ] [ ] [On-site exercise facilities or programs ] [ ] [Subsidized off-site exercise ] [ ] [Nutrition (healthy choices/availability) Organizational changes (such as route scheduling, flexibility to [ ] [ ] reduce work-home family conflicts) ] [ ] [Occupational health and safety Workforce development (such as continuing education) [ ] [ ] Other (describe): [ ] [ ] Other (describe): [ ] [ ] Other (describe): [ ] [ ]

C-7 WHP Program Environment 21) How would you agree with the following statements about your organization's worksite health promotion culture? Strongly D isagree D isagree Slightly D isagree N either A gree or D isagree Slightly A gree A gree Strongly A gree Upper management has made employee health promotion a top priority [ ] [ ] [ ] [ ] [ ] [ ] [ ] Union leadership supports and participates in the workplace health promotion program (for unionized workplaces only) [ ] [ ] [ ] [ ] [ ] [ ] [ ] Employee health promotion has been integrated with other operational administrative policies and procedures [ ] [ ] [ ] [ ] [ ] [ ] [ ] There is a person identified who has the primary responsibility for the program [ ] [ ] [ ] [ ] [ ] [ ] [ ] Others in the organization take active responsibility for the program [ ] [ ] [ ] [ ] [ ] [ ] [ ] An effective committee leads or supports the program [ ] [ ] [ ] [ ] [ ] [ ] [ ] The program links with other organizational areas, for example, occupational health and safety, benefits, etc. [ ] [ ] [ ] [ ] [ ] [ ] [ ] Workplace data is used to determine program direction [ ] [ ] [ ] [ ] [ ] [ ] [ ] The program has a long range (3-5 year) strategic plan [ ] [ ] [ ] [ ] [ ] [ ] [ ] The program responds to changing needs [ ] [ ] [ ] [ ] [ ] [ ] [ ] Management allocates adequate resources for the program (budget, space, etc.) [ ] [ ] [ ] [ ] [ ] [ ] [ ] Managers actively promote participation in health promotion activities [ ] [ ] [ ] [ ] [ ] [ ] [ ] Bus operators are actively involved in program development and implementation [ ] [ ] [ ] [ ] [ ] [ ] [ ] If you do not currently have an active WHP program, your work is done now. Please fill out the last page of the survey and return it with any questions or comments. Otherwise, please continue.

C-8 WHP Program Targets 22) Please answer both questions for each area (Select all that apply): Why did your organization start a WHP program? Which of those areas have been affected so far? ] [ ] [ stsoc erac htlaeh decudeR Lowered work-related injury or illness rates ] [ ] [ ] [ ] [ stsoc pmoc srekrow decudeR Improved availability/lessened absenteeism ] [ ] [ ] [ ] [ noitneter devorpmI ] [ ] [ tnemnorivne krow refaS ] [ ] [ serusaem htlaeh devorpmI Operational improvements (such as better on-time performance) ] [ ] [ ] [ ] [ elarom devorpmI ] [ ] [ rehtO 23) What department(s) is responsible for your WHP activities? (Select all that apply) [ ] A stand-alone health promotion program [ ] Human resources [ ] Medical/occupational health [ ] Operations [ ] Safety [ ] Other (please specify): 24) If there is a person identified who has primary responsibility for the program: What is that person's title? What % of their time is spent on the program? WHP Program Targets 25) If your organization has a worksite wellness committee, who is on it? (Select all that apply) [ ] Top Managers [ ] Line Managers [ ] Human Resources [ ] Bus Operators [ ] Union Representatives [ ] Safety Staff [ ] Other (please specify):

C-9 26) What incentives does your organization use to encourage participation in your WHP programs? (Select all that apply) [ ] None [ ] Insurance costs (reduced premiums or co-pays) [ ] Time off [ ] Cash/gift cards [ ] Individual prizes [ ] Group rewards (events, raffles) [ ] Other (please specify): 27) What external partners does your organization interact with or use as resources for your WHP activities? (Select all that apply) [ ] Health plan [ ] Workers compensation insurer [ ] Commercial vendors [ ] University or other academic center [ ] Community groups (for example, Weight Watchers, American Cancer Society) [ ] City, state or federal health departments [ ] Other (please specify): 28) Are you aware of any local or state legislation, requirements, or other policies (for example from insurance plans) that require or encourage WHP programs for transit employers? [ ] Yes [ ] No If yes, what are those local or state legislation, requirements, or other policies? WHP Program Impact 29) What health promotion needs and interests of bus operators has your organization addressed in the last 12 months? (Select all that apply) [ ] Smoking/tobacco product cessation [ ] Nutrition [ ] Weight management [ ] Cardiovascular disease prevention [ ] Responsible alcohol use

C-10 What health promotion needs and interests of bus operators has your organization addressed in the last 12 months? (continued) [ ] Stress management [ ] Work & family conflicts [ ] Threat assessment and management/violence prevention [ ] Infectious disease control [ ] Fatigue [ ] Mental health [ ] Ergonomics (adjustments, equipment, devices, body mechanics) [ ] Medical self-care and medication management [ ] Other disease management (for example, high blood pressure, sleep apnea) 30) Please answer both questions for each area (Select all that apply): What activities or policies has your organization implemented to improve work organization or the work environment? Please check if the policy or activity has had an impact on health so far. Assault or customer conflict prevention program ] [ ] [ Policies to prevent or reduce stress at work (scheduling, customer encounters, restroom access) ] [ ] [ Policies to help balance work life and family policies (family leave, phone calls) ] [ ] [ ] [ ] [Return to work accommodations Route and shift schedule policies to reduce health impact or stress ] [ ] [ Incident/near miss reporting system ] [ ] [ ] [ ] [Bathroom access policy ] [ ] [Healthy food availability Workplace health and safety inspections ] [ ] [ Other workplace health, wellness, and safety programs ] [ ] [ Other (describe): ] [ ] [ Other (describe): ] [ ] [ Other (describe): ] [ ] [

C-11 31) Approximately how many bus operators participated in your WHP program in the past 12 months? ___________ In the past 12 months, how many bus operators: Received mailings Attended required worksite meetings addressing health promotion Requested health promotion program information Participated in an optional class offered by the program (for example, exercise, tobacco use cessation, stress reduction) Completed a Health Risk Assessment (HRA) Participated in disease management activities Participated in weight loss or exercise challenges Utilized worksite exercise equipment or offsite gym access Participated in WHP program assessment or improvement activities Participated in other activities not listed 32) Please check off which areas of operations policies and practices your WHP program staff or activities have an impact on: [ ] Scheduling [ ] Hiring [ ] Safety rules [ ] Training [ ] Vendor selection (such as food or equipment) [ ] Individual work assignment/work accommodation [ ] Bus procurement [ ] Other areas of operation If you checked any of these, please describe: Program Success and Return on Investment 33) Thinking across all the health promotion, disease prevention and disease management programs your worksite offers, what do you track, and use to measure program success? 34) Does your organization calculate the Return on Investment (ROI) for the WHP program? [ ] Yes [ ] No

C-12 35) If you calculated it, thinking across all the workplace health promotion programs your worksite offers, what was your ROI in the past year? Please put an x on the line below. Dollars Recouped for Every Dollar Spent Net Loss Net Gain 0 $0.50 $1.00 $1.50 $2.00 $2.50 $3.00 $3.50 $4.00 36) Thinking across all the workplace health promotion programs, what return do you expect for these activities? Please put an x on the line below. Dollars Recouped for Every Dollar Spent Net Loss Net Gain 0 $0.50 $1.00 $1.50 $2.00 $2.50 $3.00 $3.50 $4.00 37) What is the time frame for realizing your expected ROI (select one)? [ ] Less than 12 months [ ] 12 to 17 months [ ] 18 to 23 months [ ] 24 to 35 months [ ] 36 or more months 38) What savings is your ROI based on? (Select all that apply) [ ] Health care claims cost [ ] Workers' compensation claims cost [ ] Time lost/absenteeism [ ] Disability [ ] Productivity [ ] Turnover (new hire recruitment/training) [ ] Other, please specify: _________________________________________________________ Follow-up 39) What could be done to improve your worksite health promotion program? _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ 40) May we contact you to clarify or follow up on your answers to this survey? If yes, please fill in the contact information below. Your information will be kept confidential. Name: Email Address: Phone Number: Thank you for taking the survey. Please fax, mail or email this to the address on the first page. And feel free to contact us with any questions or comments.

D-1 TCRP F-17: Improving Transit Bus Operator Health, Wellness, and Retention—Labor Survey A P P E N D I X D

D-2 Improving Transit Bus Operator Health, Wellness, and Retention— Labor Survey Welcome to the TCRP F-17 Improving Transit Bus Operator Health, Wellness and Retention survey. Your input is very important to the success of this project. Once you have collected your background information, the survey should take you about half an hour to complete. At any point you can save your answers. A special link will then be emailed to you so you can return later to your saved survey. This is especially useful as it allow you to collect and enter information at your convenience. When you have finished all the sections you click submit and the data is sent to us. Don’t worry if you don’t have all the answers. You may need to estimate, and for some questions you will not have information. We are interested in all aspects of your health and wellness activities— successful programs, the barriers you faced and even the failures. The important thing is to fill in what you can. If you are unable to do the survey for any reason, please let us know that. We hope to hear from you, and to learn from the important insight you provide. If you want to fill this out by hand, we can provide you with a hard copy. Our commitment to you: All information gathered in this survey will remain confidential and only grouped data will be shared or published. If you provide your contact information at the end of the survey, project researchers may follow up with you to get some more detailed information later in the project. Robin Gillespie, Senior Program Director for Health and Safety Transportation Learning Center 8403 Colesville Road, Silver Spring MD 20910 rgillespie@transportcenter.org (240) 230-7065 Background 1) What is the name and local number of your Union? 2) What is the name of the transit agency where you represent bus operators? ________________________________________________________________________ Note: If you have members at more than one agency, just name the one whose health promotion activities you want to describe in this survey. 3) Your title:

D-3 4) How many bus operators: Work here Work full-time Work part-time Are contracted independently or via a contract employer Are female Are under 40 Are Hispanic/Latin American Are White/Caucasian Are Black/African American Are Asian/Pacific Islander Are American Indian or Alaskan native Are other or multiple races 5) What percentage of your bus operators are dues-paying members of the union? [ ] 0% [ ] 1-25% [ ] 26-50% [ ] 51-75% [ ] 76-100% 6) What is the approximate average years of service of your bus operators? _____________ Health, Wellness and Safety Concerns 7) What are the top three health problems faced by bus operators at your agency? [ ] Chronic diseases (hypertension, diabetes, cardiovascular disease, lung disease, reflux and intestinal symptoms) [ ] Achieving desired physical activity, diet, and/or tobacco use status [ ] Wellness (such as stress and fatigue) [ ] Musculoskeletal problems (back injury, tendonitis, other pain) [ ] Work environment (accidents, work-related injuries or illnesses, assaults) [ ] Other (please specify): _________________________________________________________ 8) Have these health problems affected or led to any of the following? (Select all that apply) [ ] Increased health care costs for the agency [ ] Work-related injury or illness [ ] Excessive absenteeism, sick leave, or disability [ ] Medical disqualification for operators [ ] Loss of employment due to disability or illness [ ] Turnover/retention problems [ ] Operational problems/delays [ ] Decreased workplace morale [ ] Other (please specify): __________________________________________________________ _______________________________________________________________________________

D-4 Health, Wellness and Safety Concerns 9) How much impact do the following conditions at your workplace have on the health problems listed above? None Some A lot Route schedules [ ] [ ] [ ] Contact with riding public [ ] [ ] [ ] Hours of work [ ] [ ] [ ] Access to food [ ] [ ] [ ] Bathroom access [ ] [ ] [ ] Occupational safety or health conditions [ ] [ ] [ ] Labor/management interaction [ ] [ ] [ ] Other conditions: [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] Agency Worksite Health Promotion 10) Does your agency have a worksite health promotion (WHP) program or carry out health promotion activities that cover bus operators? [ ] Yes, active [ ] Had in the past but no longer active [ ] Not currently active but plan to restart [ ] Not yet, but plan to have in the future [ ] No to all of the above 11) If the agency does not have a program or it is not currently active, can you say why? [ ] Not needed [ ] Needed but no funds [ ] Needed but no staff resources [ ] Other, (please specify) If the agency does not have a WHP program and does not plan to start one, please go to question 18. Otherwise, please continue. 12) Describe the WHP programs or activities scope. [ ] Bus operators only [ ] All bus division staff [ ] Bus division along with other mode or division staff within the agency [ ] Municipal, multiagency, or other coordinated program or campaign (including bus operators)

D-5 13) Are or were family members involved in the WHP program? [ ] Yes [ ] No If yes, please describe: _________________________________ _____________________________________________________________________________ 14) How many years has your WHP program been active (or was it active)? __________ 15) Please state the approximate annual budget for your WHP program or activities. Then break out the components if you can. Total $ Staff $ Outreach (newsletters, advertising) $ HRAs/screenings $ Training/workshops $ Participation incentives $ Workplace changes (such as exercise facilities, food access, repairs) $ Payments to outside vendors for activities or products $ Other $ 16) For those planning a program, what will be the target of your WHP program? [ ] Chronic diseases (hypertension, diabetes, cardiovascular disease, lung disease, reflux and intestinal symptoms) [ ] Achieving desired physical activity, diet and/or tobacco use status [ ] Wellness (such as stress and fatigue) [ ] Musculoskeletal problems (back injury, tendonitis, other pain) [ ] Work environment (accidents, work related injuries or illnesses, assaults) [ ] Other (please specify): 17) If not active, when does the agency plan to begin or restart a WHP program? ________ Union Health Promotion 18) Does your Union have an independent health promotion program or carry out health promotion activities that cover bus operators?* [ ] Yes, active [ ] Had in the past but no longer active [ ] Not currently active but plan to restart [ ] Not yet, but plan to have in the future [ ] No to all of the above 19) If you do not have a program or it is not currently active, can you say why? [ ] Not needed [ ] Needed but no funds [ ] Needed but no staff resources [ ] Other, (please specify)

D-6 If you do not have a WHP program and do not plan to start one, your work on this survey is almost done. Please complete the last page and return it with any comments or questions. Otherwise, please continue. Union Health Promotion 20) Describe the WHP programs or activities scope. [ ] Bus operators only [ ] All bus division staff [ ] Bus division along with other mode or division staff within the agency [ ] Municipal, multiagency, or other coordinated program or campaign (including bus operators) 21) Are or were family members involved in the worksite health and wellness program? [ ] Yes [ ] No If yes, please describe: _____________________________________ ________________________________________________________________________________ Program Characteristics 22) What health, safety, and wellness programs are available for bus operators? (Select all that apply) . By the Employer By the Union Health risk assessments [ ] [ ] Health screenings (blood pressure/blood sugar/neck circumference/lipids/weight) [ ] [ ] Counseling/coaching [ ] [ ] Support for alternative health (for example yoga, massage) [ ] [ ] Educational messages and information [ ] [ ] Educational classes and events [ ] [ ] Policies that support a healthy environment (such as restricted tobacco product use at work or alcohol use at events) [ ] [ ] On-site exercise facilities or programs [ ] [ ] Subsidized off-site exercise [ ] [ ] Nutrition (healthy choices/availability) [ ] [ ] Organizational changes (such as route scheduling, flexibility to reduce work-home family conflicts) [ ] [ ] Occupational health and safety [ ] [ ] Workforce development (such as continuing education) [ ] [ ] Other [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ]

D-7 23) How would you agree with the following statements about your organization's WHP program? Strongly D isagree D isagree Slightly D isagree N either A gree or D isagree Slightly A gree A gree Strongly A gree Upper management has made employee health promotion a top priority [ ] [ ] [ ] [ ] [ ] [ ] [ ] Union leadership supports and participates in the workplace health promotion program [ ] [ ] [ ] [ ] [ ] [ ] [ ] Employee health promotion has been integrated with other operational administrative policies and procedures [ ] [ ] [ ] [ ] [ ] [ ] [ ] There is a person identified who has the primary responsibility for the program [ ] [ ] [ ] [ ] [ ] [ ] [ ] Others in the organization take active responsibility for the program [ ] [ ] [ ] [ ] [ ] [ ] [ ] An effective committee leads or supports the program [ ] [ ] [ ] [ ] [ ] [ ] [ ] The program links with other organizational areas, for example, occupational health and safety, benefits, etc. [ ] [ ] [ ] [ ] [ ] [ ] [ ] Workplace data is used to determine program direction [ ] [ ] [ ] [ ] [ ] [ ] [ ] The program has a long range (3-5 year) strategic plan [ ] [ ] [ ] [ ] [ ] [ ] [ ] The program responds to changing needs [ ] [ ] [ ] [ ] [ ] [ ] [ ] Management allocates adequate resources for the program (budget, space, etc.) [ ] [ ] [ ] [ ] [ ] [ ] [ ] Managers actively promote participation in health promotion activities [ ] [ ] [ ] [ ] [ ] [ ] [ ] Bus operators are actively involved in program development and implementation [ ] [ ] [ ] [ ] [ ] [ ] [ ]

D-8 Goals and Structure 24) Please answer both questions for each area (Select all that apply): Why did your agency (or Union if Union only program) start a WHP program? Which of those areas have been affected so far? Reduced health care costs [ ] [ ] Lowered work-related injury or illness rates [ ] [ ] Reduced workers comp costs [ ] [ ] Improved availability/lessened absenteeism [ ] [ ] Improved retention [ ] [ ] Safer work environment [ ] [ ] Improved health measures [ ] [ ] Operational improvements (such as better on-time performance) [ ] [ ] Improved morale [ ] [ ] Other [ ] [ ] 25) What groups are responsible for your WHP activities? (Select all that apply) [ ] The Union [ ] A stand alone-health promotion program [ ] Human resources [ ] Medical/occupational health [ ] Operations [ ] Safety [ ] Other (please specify) 26) If there is a person identified who has primary responsibility for the program: What is that person's title? ____________________________________________ Goals and Structure 27) If your organization has a worksite wellness committee, who is on it? (Select all that apply) [ ] Top Managers [ ] Line Managers [ ] Human Resources [ ] Bus Operators [ ] Union Representatives [ ] Safety Staff [ ] Other (please specify)_____________________________________________________________

D-9 28) What incentives does your organization (or Union if Union-only program) use to encourage participation in your WHP programs? (Select all that apply) [ ] None [ ] Insurance costs (reduced premiums or co-pays) [ ] Time off [ ] Cash/gift cards [ ] Individual prizes [ ] Group rewards (events, raffles) [ ] Other (please specify): 29) What external partners does your organization (or Union if Union only program) interact with or use as resources for your WHP activities? (Select all that apply) [ ] Health plan [ ] Workers compensation insurer [ ] Commercial vendors [ ] University or other academic center [ ] Community groups (for example, Weight Watchers, American Cancer Society) [ ] City, state or federal health departments [ ] Other (please specify): Goals and Structure 30) Are you aware of any local or state legislation, requirements, or other policies (for example from insurance plans) that require or encourage WHP programs for transit employers? [ ] Yes [ ] No If yes, what are those local or state legislation, requirements, or other policies? Targets and Involvement 31) Please describe the role of the Union in the health promotion program and activities: ____________________________________________________________________________

D-10 32) What health promotion needs and interests of bus operators has your organization addressed in the last 12 months? (Select all that apply) [ ] Smoking/tobacco product cessation [ ] Nutrition [ ] Weight management [ ] Cardiovascular disease prevention [ ] Responsible alcohol use [ ] Stress management [ ] Work and family conflicts [ ] Threat assessment and management/violence prevention [ ] Infectious disease control [ ] Fatigue [ ] Mental health [ ] Ergonomics (adjustments, equipment, devices, body mechanics) [ ] Medical self-care and medication management [ ] Other disease management (for example, high blood pressure, sleep apnea) [ ] Other (please specify) _______________________________________________________ ____________________________________________________________________________ 33) What activities or policies has your employer implemented to improve work organization or the work environment? Please check if the policy or activity has had an impact on health so far (Select all that apply): Activity Has had an impact Assault or customer conflict prevention program [ ] [ ] Policies to prevent or reduce stress at work (scheduling, customer encounters, restroom access) [ ] [ ] Policies to help balance work life and family policies (family leave, phone calls) [ ] [ ] Return to work accommodations [ ] [ ] Route and shift schedule policies to reduce health impact or stress [ ] [ ] Incident/near miss reporting system [ ] [ ] Bathroom access policy [ ] [ ] Healthy food availability [ ] [ ] Workplace health and safety inspections [ ] [ ] Other workplace health, wellness, and safety programs [ ] [ ] Activity Has had an impact Other policies or programs [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ]

D-11 Targets and Involvement 34) How many bus operators participated in your health promotion program in the past 12 months? [ ] all or most [ ] less than 75% [ ] around half [ ] less than a third [ ] few 35) How did bus operators participate in the last 12 months? [ ] Received mailings [ ] Attended required worksite meetings addressing health promotion [ ] Requested health promotion program information [ ] Participated in optional classes offered by the program (for example, exercise, tobacco use cessation, stress reduction) [ ] Completed a Health Risk Assessment (HRA) [ ] Participated in disease management activities [ ] Participated in weight loss or exercise challenges [ ] Utilized worksite exercise equipment or offsite gym access [ ] Participated in worksite assessment or improvement activities [ ] Other (please specify) 36) Does the workplace health promotion program staff or activities have any influence on any other areas of operations policies and practices? [ ] Scheduling [ ] Hiring [ ] Safety rules [ ] Training [ ] Vendor selection (such as food or equipment) [ ] Individual work assignment/work accommodation [ ] Bus procurement [ ] Other areas of operation Targets and Involvement 37) Does the workplace health promotion program staff or activities have any influence on any other areas of operations policies and practices? If you checked any of these, please describe:

D-12 38) Thinking across all the health promotion, disease prevention and disease management programs and activities the worksite offers, how would you say these affected the following in the last 12 months Improves Has no effect Makes worse Health status [ ] [ ] [ ] Healthy behavior [ ] [ ] [ ] Occupational injury or illness rates [ ] [ ] [ ] Time lost/absenteeism/disability [ ] [ ] [ ] Operational improvements including employee availability [ ] [ ] [ ] Turnover rates/retention [ ] [ ] [ ] Health care claims cost [ ] [ ] [ ] Other [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] [ ] Follow-up 39) What could be done to improve your WHP program? __________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 40) May we contact you to clarify or follow up on your answers to this survey? If yes, please fill in the contact information below. Your information will be kept confidential. Name: _________________________ Name of Your Organization: _________________________ Your Title: _________________________ Email Address: _________________________ Address: ____________________________________________________________________ ____________________________________________________________________________ Phone Number: _________________________ Thank you for taking the survey. Please fax, mail or email this to the address on the first page. Your response helps ensure that union members can contribute to building healthy and safe workplaces. And feel free to contact us with any questions or comments.

E-1 F-17 Survey Follow-Up Data Collection Guidelines Survey Follow-Up Data Collection Guidelines Follow-up data collection will take place in three stages. First, all survey respondents who agree will be contacted and asked a brief set of questions. Next, a smaller number of agencies will be selected for in-depth interviews. Finally, some agencies will be asked to provide more detailed quantitative data. The purpose for the brief follow-up questions is to clarify information already recorded and get information that could not easily be collected in the survey format that will help distinguish programs and activities. These will target everyone who provides follow-up contact information. Depending on how completely surveys are filled out we will ask only the questions below or will probe to clarify incomplete responses to the survey. The purpose of the in-depth interviews, in contrast, is to test and support the structure for the best-practice guidelines—find out what people are doing as intervention and for ROI, and see what corresponds to our developing model of good practice; find out more about the depth of involvement and collaboration; and explore the subsidiary issues such as workforce development and training. The questions asked will depend in part on how the surveys are filled out and what gaps we see. Because important avenues of inquiry, as well as gaps in the data, may become apparent only after survey data has been collected, these questions may evolve from the current format. Question sources include: 1. Evans D., Hierarchy of evidence: a framework for ranking evidence evaluating healthcare interventions. Journal of Clinical Nursing 2003;12:77–84. 2. Engbers L., Monitoring and Evaluation of Worksite Health Promotion Programs—Current state of knowledge and implications for practice. In: WHO/WEF Joint Event on Preventing Noncommunicable Diseases in the Workplace; 2008; Dalian, China: World Health Organiza- tion; 2008. 3. Chapman, L.S., Proof Positive: An Analysis of the Cost Effectiveness of Worksite Wellness; Chapman Institute, 2008. 4. National Association of Chronic Disease Directors, A Practical Guide to ROI Analysis, 2009. 2009. A P P E N D I X E

E-2 Question F-17 target What were the health outcomes of your program (if not clear from survey response)? What was the financial impact of your program (if not clear from survey response)? Conditions that affect health if they marked no—why not? How do you decide what activities to carry out or what targets? (Probe—surveys, use data, “we just know.”) Of all the things you did, what worked best? Were there any disadvantages to your health promotion program or activities? What do you think makes a good program? If you were to explain to another [agency/union leader] how to start up an effective workplace health promotion program, could you tell them: How will it be accepted and used by workers? How should it be implemented (what steps are needed to get and keep it going) ? What resources are required? (people, money, time) What are the economic implications of the program? Area Effectiveness, evaluation Effectiveness, evaluation Planning Planning Effectiveness, evaluation Effectiveness, evaluation Effectiveness, evaluation Feasibility Feasibility Feasibility Feasibility 22 22 3 3 22 22 22 8 9-15 5 5, 16-18 Is it ok to use your agency’s name when reporting your case description? Is it ok to use your local’s name when reporting your case description? Is there any additional documentation on your program or its outcomes that you would like to share? What health issues are most important to the transit bus operators? Appropriateness 22 Describe how the program was planned and developed— include the role of frontline workers, operations managers, union leadership, program staff, and others. Participation, planning 9, 19 Can you tell us more about how program components and services were provided? Implementation 9, 11, 12 Describe any collaboration between departments. (probe based on survey results) Integration 6, 9, 10 How are WHP targets chosen? Who is involved? What criteria? Planning 9, 10 Case Example Follow-up Questions.

E-3 Question F-17 target Area What proportion of the eligible population participated in the program? Participation 8 Does your program address accommodations for people returning from disability or injury? Implementation, integration 11, 12 How much did participants follow through on initial contacts and commitments? Was progress maintained? How did you assess that? Impact 14, 22 Was the program acceptable for the target population (met needs, confidentiality, interest, time available)? Did they like it/own it/support it? How did you assess acceptance? Organization support 8, 10, 19 Did concerns about confidentiality arise? On the part of management, the union, or individuals? How were they addressed? (HRAs, biometrics, workshops, requesting assistance, pointing out workplace problems) Implementation 9, 10, 14 Are bus operator qualifications and education programs and activities linked to health and wellness? (for ex., CDL, retention, promotion) Integration 6, 12, 16, 17 If yes, how does your program address qualifications and education? (Probe for tuition reimbursements, career ladder, specialized safety training, peer health activist training) Integration 11, 12, 14 Does the WHPP program assess physical demands of work in the context of wellness—such as exercise? (could include pedometers, job safety analysis) Integration 11, 12 Can you describe any problems encountered in implementing the program? How were they resolved? Implementation 22 If objectives, plans, or timetables were revised, why was this necessary? Implementation, evaluation 22 How did the data collection take place; how was the data collected? (probe for baseline, participation, outcomes) Evaluation 4 Does the program work? Were your goals met? Did unintended positive developments occur? What do you base this on? (probe based on survey responses) Effectiveness, evaluation 22 What costs (materials, measurements, management,) were incurred? Did they exceed initial projections? Cost, evaluation 22 Do you know of any other activities that might have affected your program outcomes (commercial health services, questionnaires, competing interests, budget constraints, manpower limitations) in progress at the worksite during your program? If yes what was the impact? Contributors and barriers 20, 22 What is the most effective thing you did? Why do you say this? 22 What is the least effective thing you did? Why? 22 Is there any potential harm of your program? 22 Effectiveness, evaluation Effectiveness, evaluation Effectiveness, evaluation Case Example Follow-up Questions.

E-4 Question F-17 target Area Describe the impact, if any, on retention. 6, 18 Describe the impact, if any, on the safety culture. 14, 15 What about the overall of culture of health—did this change at all? 14, 15 Who in your experience benefits most from the program? 22 What is the experience of the transit bus operators with the program? Does it differ between shifts, genders, ages, other groups? 22 Do the operators view the outcomes as beneficial? 22 Describe the labor/management partnership in the program. Was it important to success? How could it be enhanced? 6, 9, 10, 19 What external partners or resources did you enlist? Were they helpful? What was the impact on costs/savings? 20 What are you planning to do next with this program? Effectiveness, evaluation Effectiveness, evaluation Effectiveness, evaluation Effectiveness Effectiveness, evaluation Effectiveness, evaluation Integration, partnership Integration, partnership Planning Case Example Follow-up Questions. Quantitative Data Collection Guidelines As part of the in-depth case study, the project team will work with health promotion program coordinators and other agency personnel, such as human resources, IT, and safety departments, to collect detailed quantitative data from the agency’s analysis of their program outcomes and ROI, if available. The goal is to access existing aggregate program outcome measurements com- piled by the selected agencies, rather than collecting raw, individual case data. The main purpose is to identify and evaluate measures and activities currently in place in order to support the best- practice guidelines, rather than to assess the efficacy of a given program. Depending on availability and accessibility, data to be collected may include the following as data or in prepared report form if available: Participation 1. List the specific health promotion program events or activities you have carried out in the past year, including the number of times you did each. 2. State the number of people participating in each area of activities of your health promotion program (if not already provided in survey). 3. If possible, can you describe how the amounts are calculated—for example, estimated, sign-in sheets, reports from vendors; also, are they unique users or total number of hits or visits? Evaluation 1. How do you define program success? 2. What specific data sources do you collect? How often do you take measurements?

E-5 3. What do you track in terms of program outcomes? And how are these measures defined (for example, absenteeism, retention, etc.)? The kinds of answers you might give to this and the following questions are illustrated in the table below. Changes in behaviors for x: Smoking—self report in annual survey, requests for patches Exercise—gym sign-in sheets, membership sign-ups, step counters Health status (blood pressure, weight, blood sugar, etc.) for x: Aggregate HRA reports Screenings at depots quarterly, reports provided by vendor CDL qualifications data provided by HR Absenteeism/time lost for x: Overall, or for individuals participating in programs Medical disqualification for x: Informal listing or knowledge of CDL or employee health services decisions Annual review of disability findings Health care claim costs for x: Condition-specific data from health plan, annually Overall costs from broker or other pool source, quarterly Worker’s compensation claims for x: From insurer, by condition, with advice or required improvements Disability costs (in particular short term) for x: Human resources monthly reports, not separated by conditions Workplace injuries, accidents, or conditions for x: OSHA 300 logs, monthly, from risk management Summary annual reports by division Monthly notes from safety committee meetings reviewed by wellness team Retention 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 4. How are these measures related to the original program goals you set out to achieve? 5. What data collection forms do you use? 6. Which departments and employees (job titles) are involved in the data collection process and specifically what data sets do they provide? 7. Can you describe how you use evaluation data? For example, use participant or employee sur- vey data to adjust program scheduling for better participation, use health plan cost changes to obtain additional funding for program? 8. Can you share any reports on the program outcomes, such as annual reports, quarterly cost assessments, strategic plans? You can send those via mail or email. 9. It will help us to see any examples of the data you have so we can see how it fits in to our tools. Please provide what you think you can share, and we will discuss other options in our further talks with you.

E-6 Cost and Benefits/ROI 1. What do you track in terms of program costs (if not already provided in survey)? 2. How are the program benefits converted into dollar savings (esp. absenteeism, productivity increase, turnover, etc.)? 3. How much do you think the program has contributed to any observed benefits? Which par- ticular activities have contributed in what ways? 4. What additional considerations do you have when calculating cost vs. benefits or ROI? 5. If you have not done cost and benefits analysis before or are looking to expand your current analysis, what type of tools or other assistance could help you achieve that?

F-1 Case Study Agency Snapshots A P P E N D I X F A. LACMTA Program Snapshot (F-17 Survey Results): Fixed-Route Bus Annual Ridership Number of Operators Union Representation Average Years of Service Survey Responses >20M 5138 United Transportation Union Locals 1563, 1564, 1565, 1607, 1608 23 UTU Trust Fund manager and management Top 3 Health Problems: Chronic diseases Achieving desired physical activity, diet, and/or tobacco use status Musculoskeletal problems (back injury, tendinitis, or other pain) Conditions Affecting Health: None Noted Program summary: Program Activities Health risk assessments Health screenings Counseling/coaching Support for alternative health programs Educational messages and information Educational classes and events Onsite exercise facilities or programs Subsidized off-site exercise Nutrition Model Traditional Structure/ Committee This is a stand-alone program but Human Resources, Operations and Safety play a role. The program is run by a full-time Wellness Manager and supported by onsite Champions and Ambassadors. The wellness committee consists of Top Managers Line Managers Human Resources Transit bus operators Union Representatives Safety Staff Healthcare Providers

F-2 Work and family conflicts Mental health Other disease management Related policies and programs (programs with impact to date are bolded) Healthy food availability Targets Achieved Improved morale Evaluation Program success is tracked and measured by: Program participation rates Employee feedback Health care claims cost Employee availability ROI No ROI studies have been done. Estimated positive return within a 36 month period, based on: Health care claims cost Productivity Health Promotion Focuses Smoking/tobacco product cessation Nutrition Weight management CVD prevention Responsible alcohol use Stress management B. Dallas Program Snapshot (F-17 Survey Results) Fixed-Route Bus Annual Ridership Number of Operators Union Representation Average Years of Service Survey Responses >20M 1641 ATU Local 1338 11 Management and Union Top 3 Health Problems: Management Response Union Response Chronic diseases Chronic diseases Achieving desired physical activity, diet, and/or tobacco use Achieving desired physical activity, diet, and/or tobacco use Work environment (accidents, work-related injuries or illnesses, assaults) Musculoskeletal problems (back injury, tendinitis, or other pain) Conditions Affecting Health: Management Response: Union Response: Route schedules (Some) Route schedules (A lot) Contact with riding public (Some) Contact with riding public (Some) Hours of work (Some) Hours of work (Some)

F-3 Program Summary: Company Program Status Current Length 7 years Activities (italicized if part of other program) Health risk assessments Health screenings Counseling/coaching Support for alternative health (for example yoga, massage) Educational messages and information Educational classes and events Policies that support a healthy environment (such as restricted tobacco product use at events work or alcohol use at events) Onsite exercise facilities or programs Nutrition (healthy choices/availability) Occupational health and safety Workforce development Model Integrated Access to food (A lot) Access to food (A lot) Bathroom access (A lot) Occupational safety or health (Some) Occupational safety or health (Some) Labor/management interaction (A lot) Labor/management interaction (Some) All levels of staff and job divisions Health Promotion Focuses Smoking/tobacco product use cessation Nutrition Weight management CVD prevention Infectious disease control Fatigue Mental health Medical self-care and medication management Other disease management Related Policies and Programs (programs with impact to date are bolded; they are italicized if they are union responses only) Policies to help balance work life and family policies (family leave, phone calls) Return to work accommodations Other workplace health, wellness, and safety programs Assault or customer conflict prevention program Incident/near-miss reporting system Targets Achieved Reduced workers comp costs Improved health measures Improved morale Structure/Committee Human Resources are responsible for their health and wellness program. They have a worksite wellness committee that includes: Top managers Line managers Human resources Transit bus operators Union representatives Safety staff

F-4 Evaluation Program success is tracked and measured by: Program participation rates Employee feedback Behavior change Health status Health care claims cost Workers’ compensation claims cost Time lost/absenteeism Disability Cause of death conditions. ROI They do not calculate ROI. C. Edmonton Program Snapshot (F-17 Survey Results) Fixed-route bus annual ridership Number of operators Union representation Average years of service Survey responses >20M 1536 76-100 percent 13 Management and Union Top 3 Health Problems: Chronic diseases Wellness Musculoskeletal problems Conditions Affecting Health: Route schedules (Some) Contact with riding public (Some) Hours of work (Some) Access to food (Some) Bathroom access (Some) Occupational safety and health conditions (Some) Labor/management interaction (Some) Program Summary: Company Program Status Current Length 15 years Activities (italicized if part of other program) Health risk assessments Health screenings Counseling/coaching Support for alternative health (for example yoga, massage) Educational messages and information Educational classes and events Subsidized off-site access Nutrition (healthy choices/availability) Occupational health and safety Model Integrated

F-5 Structure/Committee Human Resources and Operations are responsible for the health and wellness program. They have a worksite wellness committee including: Line managers Human resources Transit bus operators Union representatives Wellness consultant Health Promotion Focuses Nutrition Weight management Stress management Threat assessment and management/violence prevention Mental health Related Policies and Programs (programs with impact to date are bolded) Assault or customer conflict prevention program Return to work accommodations Incident/near-miss reporting system Workplace health and safety inspections Other workplace health, wellness, and safety programs Targets Achieved Lowered work-related injury or illness rates Safer work environment Improved health measures Evaluation Program success is tracked and measured by: Program participation rates Employee feedback Behavior change Workers’ compensation claims cost Time lost/absenteeism Disability ROI No ROI studies have been done. Agency would expect a $2 return for every $1 invested within a 18-23 month time period, based on: Workers’ compensation claims cost Time lost/absenteeism Disability D. OCTA Agency Snapshot (F-17 Survey Results) Fixed-route bus annual ridership Number of operators Union representation Average years of service Survey responses > 20 million 958 76-100 percent 13 years of service Management and Union Top 3 Health Problems: Management Response Union Response Chronic diseases (hypertension, diabetes, CVD, lung disease, reflux and intestinal symptoms) None listed Wellness (such as stress and fatigue) Musculoskeletal problems (back injury, tendinitis, other pain)

F-6 Conditions Affecting Health: Management Response Union Response Route schedules (Some) Route schedules (A lot) Contact with riding public (Some) Contact with riding public (Some) Occupational safety or health conditions (Some) Hours of work (Some) Bus and/or Operation station design Access to food (Some) Ergonomics Bathroom access (A lot) Wheelchair handling Occupational safety or health conditions (Some) Labor/management interaction (Some) Program Summary: Company Program Status Current Length 21 years Activities (italicized if part of other program, Health risk assessments Health screenings (high blood pressure/blood sugar/neck circumference/lipids/weight) bolded and italicized if part of workplace program and other program) Counseling/coaching Support for alternative health (for example yoga, massage) Educational messages and information Educational classes and events Policies that support a health environment (such as restricted tobacco product use at work or alcohol use at events) Onsite exercise facilities or programs Nutrition (health choices/availability) Occupational health and safety Workforce development (such as continuing education) Annual Health Fairs for each location 3 incentive contests addressing healthy eating, exercise and/or stress management 2 physical activity events open to family and friends; Intramural sport activities; Incentive program for employees to receive points for participation in physical activity Model Integrated Structure/ Committee Safety is responsible for the health and wellness program. They have a worksite wellness committee composed of: Transit bus operators Safety staff Administration and Maintenance representatives Health Promotion Focuses Smoking/tobacco product cessation Nutrition Weight management CVD prevention Work and family conflicts Infectious disease control Ergonomic (adjustments, equipment, devices, body mechanics) Other disease management (for example high blood pressure)

F-7 Related Policies and Programs (programs with impact to date are bolded) Assault or customer conflict prevention program Policies to prevent or reduce stress at work (scheduling, customer encounters, restroom access) Policies to help balance work life and family policies (family leave, phone calls) Return to work accommodations Incident/near-miss reporting system Bathroom access policy Healthy food availability Workplace health and safety inspections Other workplace health, wellness, and safety programs Smoke-free Workplace Policy (impact not measured) Communicable Disease Policy (impact not measured) Workplace Violence Policy (impact not measured) Targets Achieved so far Reduced health care costs Evaluation Program success is tracked and measured by: Program participation rates Employee feedback ROI No ROI studies have been done. Agency would expect an ROI within less than 12 months. E. Capital Metro Program Snapshot (F-17 Survey Results) Fixed-route bus annual ridership Number of operators Union representation Average years of service Survey responses > 4M and < 20M 668 26-50 percent ATU Local 1091 11 years of service Manage- ment Top 3 Health Problems: Management Response Chronic diseases Achieving desired physical activity, diet, and/or tobacco use status Musculoskeletal problems Conditions Affecting Health: Management Response Access to food (Some) Other: Tobacco free policies have positive impact on reducing tobacco use and related health issues Program Summary: Company Program Status Current Length 9 Years

F-8 Activities (italicized if part of other program) Health risk assessments Health screenings (high blood pressure/blood sugar/neck circumference/lipids/weight) Counseling/coaching Support for alternative health (for example yoga, massage) Educational messages and information Educational classes and event Onsite exercise facilities or programs Nutrition (healthy choices/availability) Organizational changes (such as route scheduling, flexibility to reduce work- home-family conflicts) Occupational health and safety Workforce development (such as continuing education) Other: Disease management, free tobacco cessation, onsite weight loss program, free tobacco cessation meds, nurse helpline, free personal trainer, onsite nutritionist. Model Health and Productivity Structure/ Committee Human Resources and Risk Management are responsible for the health and wellness program. They have a worksite wellness committee involving: Line managers Human Resources Transit bus operators Union representatives Admin staff Mechanics Health Promotion Smoking/tobacco product cessation Nutrition Focuses Weight management CVD prevention Responsible alcohol use Stress management Infectious disease control Mental health Ergonomics (adjustments, equipment, devices, body mechanics) Other disease management (for example, high blood pressure, sleep apnea) Related Policies and Programs (programs with impact to date are bolded) Return to work accommodations Incident/near-miss reporting system Health food availability Workplace health and safety inspections Other workplace health, wellness, and safety inspections Tobacco free policies to reduce second hand exposure Improved access to healthier food that are subsidized by the Authority Bike loan programs Targets Achieved so far Lowered work-related injury or illness rates Improved availability/lessened absenteeism ROI Calculated ROI: $2.43 Agency expects a return in 36 months or more, based on health care claims costs and time lost/absenteeism

G-1 Transit Agency Materials and Reports A P P E N D I X G UTU-LACMTA Presentation: Starting A Wellness Program: Best Practices London Transit Transportation Services Guide London Transit Wellness Committee Tracking Form OCTA Ergonomic Checklist for Coach Operators

G -2 Starting A Wellness Program: Best Practices United Transportation Union - Los Angeles County Metropolitan Transportation Authority Summary of Best Practices • Strategic Planning – Identify health conditions and risk factors driving costs, employee interests, and needs. – Establish measurable goals and objectives with deadlines. – Align plan and benefit design to help achieve goals. • Engagement of Labor, Management, Employee Leadership, and Health Plans – Executive and Middle Levels. – Each Union Local and all Employer/Management Departments. – Employee level/Wellness Champions to represent all work shifts. – Wellness Committee leadership and program coordination. Summary of Best Practices cont. • Determination of Programming – Worksite: biometric screenings, learning centers, seminars/workshops. – Worksite challenges and contests. – Health Plan disease management, disease prevention,EAP, Wellness Programs. – Targeted health issues and programs. – Calendar of events, activities, Wellness Ambassador training, etc. • Engagement Methods – Communication channels (Union, Employer, Health Plans) – Incentives, reward, kick-off event, challenges, contests. – Theme, key messages. – Mail, posters, payroll stuffers, email, Wellness Ambassadors/word of mouth, newsletters, social media, testimonials, etc. • Evaluation – Participation, healthcare utilization, cost, risk factors, changes in lifestyle and behavior, employee testimonials, and satisfaction surveys. – Measure and results to all stakeholders (union, management, and members). Establish A Committee • Possible candidates include: Union officials, key management leaders, healthcare providers, and local educational organizations (AHA, ADA, ACS) • This allows delegation of responsibilities and duties for the program. • Establish a regular meeting schedule and meeting place. • Record minutes at each meeting.

G -3 Strategic Plan • Identify the direction in which the committee would like to steer your wellness program over the next 3-5 years. • It is necessary to understand your committee’s current position and the course of action you wish to take to achieve the overall long term goal, set by the committee. • Be sure to address key points when formulating your strategic plan: – Long Term goal (over the next 3-5 years) – Short Term annual goals – Target group – Task setting – Measures Annual Plan • This is your “road map” that helps you achieve your strategic plan. • Detailed outline of the timeline/action items that will take place throughout the year. • Should be designed to complement your short term goals indicated in the strategic plan. Budget • Record all of your sources of revenue. • Identify your goals and the programs/events you intend to implement for the year. • Create a list of monthly/annual expenses based on your programs/events. • Total your monthly expenses and compare them to your revenue. • Make adjustments as needed, throughout the year to ensure your budget does not negative spend. • Allocate a surplus/reserve for any unexpected expenses/events. Branding • Branding commands a presence, expresses your program’s vision, and provides an experience for your participants. • Wellness Program Logo • Annual T-Shirt Logos

G -4 Ambassadors/Champions • Select people that are supportive of your wellness program. • Ambassadors should be peers of your target group. • Utilize middle management to support your Champions, especially since they also work closely with your target group. • Include alternate representatives to your support team, so your program can remain fluid, consistent, and can cover all work shifts. • Include both Union and Management Champions who will support each other and promote the program. • Empower your support team with proper training, resources, and incentives, so they can represent your program to the fullest. Lessons Learned, What Works Well • Following a standard way of doing things helps to maintain a consistency throughout your program. • Regularly scheduled meetings/training for Ambassadors, Champions, and committee. • Consistently scheduled programming throughout the year. • Prompt “Rewards and Recognition” for both participants and Ambassadors/Champions/Committee. • Utilize “templates” to standardize the process of documentation. – Participation tracking/daily sign-in forms. – Interest Surveys and bi-annual “How Are We Doing?” surveys. – Facts sheet/guidelines for exercise and nutrition. – Success story guidelines with examples. – Data recording and reporting. Health Fairs • Identify your goals and theme for your health fair • What services will you provide? (health screenings, health coaches, educational tools, etc.) • Will you incentivize participation? • Advertisement/Promotion is KEY for achieving participation goals. • What outcomes can be extracted from this event? • Be certain that you gain “buy-in”, from your location’s management department, for your event. Seminars • Collaborate with the experts, such as the American Heart Association, American Diabetes Association, or your benefits healthcare providers, to help you coordinate educational seminars at your site(s). • Advertisement/Promotion is KEY for achieving participation goals. • Use your program data (interest surveys, health fair results, strategic plan, and annual plan) to determine what the topic for discussion should be. • Survey the participants, as a measure to determine how effective and valuable the seminar was.

G -5 Measurement Tools • To best determine the effectiveness of your program, it is essential to gather both “soft data” and “hard data”. • Soft data: – Participant Surveys for the overall program – Program numbers for various events – Health Fair screening results – Educational Seminar surveys Measurement Tools cont. • Hard Data : – Establish baseline data and measure changes in health care utilization, costs, employee health risk factors, and annual premium rates over time. – Healthcare provider reports and upward/favorable trends for your population. – Decrease in workers compensation claims or industrial injuries. – Decline in employee’s leave of absence. Key Take-Away’s • Identify Key people that respect and value your wellness program. • Identify your goals for the program and create a strategic plan that will compliment your goals. • Create an annual plan and budget that is harmonious with one another. • Formulate “Best Practices” as a means to establishing continuity in your program. • Pinpoint what measurements will be used when comparing your program’s results to the goals set in your Strategic Plan. Addendum

G -6 Strategic Plan Strategic Plan April 2012- March 31, 2013 Wellness and Health Insurance Cost Containment Strategy (WCCS) Key Strategies for 2012-2013 Long Term Goals: • Improve UTU-TCU-ASCME-MTA member health • Establish and grow a strong “health culture” within the UTU-TCU-ASCME-MTA organizations. • Limit health plan annual premium rate increases to less than the Southern California healthcare trend. Short Term: • 15% participation in worksite fitness programs/contests (Metro Fit Club, walking, gym utilization, etc.) • 15% participation in annual Health Fairs at all locations. Health Fairs to include education, screening, 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). 2012-2013 Objectives • Evaluate the targeted disease management wellness programs. ** • Maintain a retention rate of at least 6% of current members in existing programs for 2012, 7 % in 2013, and 8 % in 2014. • Develop a formal plan for the expansion and continuity of the UTU-MTA Wellness program. ** • Maintain an annual volunteer performance review, reward, and recognition program. ** • Offer outside trainings and certifications for Wellness Ambassadors. ** • Increase program options and availability for members, by establishing a new program/event each year as a means to continually “plus” the Wellness program’s participation totals. ** • Identify methods to track and report results linking those results to changes in employee’s health status, healthcare utilization and costs. ** • Conduct a bi-annual member satisfaction survey and implement action plans based on the survey results. ** • Establish a collaboration on a local level (local stores, government, parks and recreation, schools, etc.), through formal agreements and commitments, to further strengthen the program. ** • Develop a community action plan that illustrates the MTA-UTU’s commitment to a “Healthy Lifestyle” (i.e.-healthy meeting meals/nutritional data reporting, adopting a bike trail, establishing a 5k run/walk, fitness challenge association-wide, etc.). ** • Develop a joint labor-management work plan that establishes program objectives and services, stakeholder roles and an implementation timeline that results in all LAMTA employees and their dependents actively participating in a companywide wellness and cost containment program on a year-round basis (including exempt employees and UTU, TCU, AFSCME, and eventually ATU and TEAMSTERS). • **will be continuous throughout 2012-2014 Strategic Plan Continued Key Strategies for April 2013-March 2014 Long Term Goal: • Improve UTU-MTA member health • Establish and grow a strong “health culture” within the MTA and UTU organizations • Limit health plan annual premium rate increases to less than the Southern California healthcare trend. Short Term Goal: • 6% completion rate in each carrier’s web-based programs (HRA, nutrition, exercise, smoking cessation, weight management, stress management) through a pilot program (March – August 2013) at Division 10. • 18% participation in worksite fitness programs/contests (Metro Fit Club, walking, gym utilization, etc.) • 18% participation in annual Health Fairs at all locations. Health Fairs to include education, screening, wellness coaching, and referral to year-round wellness programs (web-based programs, exercise, weight loss, and seminars). • 18% participation in various seminars (stress management, vendor sponsored events). 2013-2014 Objectives • Encourage and support a healthy lifestyle for all of the member’s nuclear family, by including families in recreational events, which strengthens familial ties, especially when seeking out to change behavioral lifestyle modifications. This is what makes the UTU-MTA Wellness program unique and stand out above other wellness programs. • Expand, improve, and alter the facility resources of all sites, as needed, to meet service objectives. • Utilize “Moves Management” to move perspective/infrequent participants to regular participants, to “co-owners” of the program. • Improve overall internal communication by improving the utilization of the UTU website, linking the UTU website with the MTA website, adding carrier links to both websites whenever possible, implementing a newsletter. Strategic Plan Continued • Key Strategies for April 2014-March 2015 Long Term Goal: • Improve UTU-MTA member health • Establish and grow a strong “health culture” within the MTA and UTU organizations • Limit health plan annual premium rate increases to less than the Southern California healthcare trend. Short Term Goal: • 7% completion rate in each carrier’s web-based programs (HRA, nutrition, exercise, smoking cessation, weight management, stress management) at all divisions. • 21% participation in worksite fitness programs/contests (Metro Fit Club, walking, gym utilization, etc.) • 21% participation in annual Health Fairs at all locations. Health Fairs to include education, screening, wellness coaching, and referral to year-round wellness programs (web-based programs, exercise, weight loss, and seminars). • 21% participation in various seminars (stress management, vendor sponsored events). 2014-15 Objectives • Create a Wellness Council within the Wellness Ambassadors to promote ownership within its’ own membership. • Develop an action plan that highlights the UTU-MTA’s commitment to a Wellness Program by highlighting the program in the community (i.e.-public forums, trainings, conferences, expos, etc.). • Develop a capital campaign that will raise funds for the development and improvements of the gym conditions of all the divisions. • Develop an action plan that looks at and focuses on grant/charitable programs. Example of an Annual Plan Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Objecve To provide informaon to members regarding various health issues. Programming Bullen Boards Aetna UHC Delta EAP Optum DHS Aetna Kaiser Anthem Shortcuts for SMART Weight Loss Kaiser MHN Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Objecve Instute non fee based Incenve Programs that plusses the Wellness Program parcipaon year-round. Programming Incenve Programs Metro Fit Club OCTA-MTA 10k ADA Walk/AHA WALK Fitness Challenge Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Objecve To provide educaon on health issues, treatment, and prevenon trends from healthcare professionals. Programming Health Fairs RCC- 3/27/2013 Division 7- 4/24/2013 Division 3- 5/22/2013 Division 11- 6/05/2013 Division 5- 7/17/2013 Division 1- 8/28/2013 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Objecve To provide fun non fee based challenges that foster posive compeon among the members. Programming Quarterly Challenges Push Up Challenge Sit up Challenge Hula Hoop Challenge Jump rope Challenge Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Objecve To provide low cost health screenings that are conveniently located for the members. Programming Health Screenings Blood pressure/BMI Blood Panel-Cholesterol Body Composion Blood Panel-Diabetes Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Objecve To offer various clinics designed to provide basic knowledge of weight management tools and techniques. Programming Focus Informaon/Seminars/Clinics Caloric Calulaons The Fat in Our Food Poron Size Sugar in Our Drinks Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Objecve To offer connuous educaon and support for the wellness ambassadors. Programming Trainings/Discussion groups Quarterly Meengs Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Objecve To offer friendly game play that promotes commodore amongst the various groups of MTA. Programming Intramural Play Soball Tournament Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Programming Fee based Lunch and Learn provided by Healthcare providers, offered throughout the year. Nutrionist

G -7 Annual Calendar January 2013 S M T W T F S 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 April 2013 S M T W T F S 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24* 25 26 27 28 29 30 July 2013 S M T W T F S 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17* 18 19 20 21 22 23 24 25 26 27 28 29 30 31 October 2013 S M T W T F S 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 February 2013 S M T W T F S 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 May 2013 S M T W T F S 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22* 23 24 25 26 27 28 29 30 31 August 2013 S M T W T F S 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28* 29 30 31 November 2013 S M T W T F S 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 March 2013 S M T W T F S 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27* 28 29 30 31 June 2013 S M T W T F S 1 2 3 4 5* 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 September 2013 S M T W T F S 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 December 2013 S M T W T F S 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Wellness Wednesday Committee Meeting Ambassador Meeting January Div 5 -1/9, Div 1- 1/16 Div 2-1/30, Div 10-1/30s February Div 6-2/13, Div 3-2/20, Div 7-2/27 March Div-8-3/13, Div 9-3/20, GTW-3/26, Div 1-3/13s April Div 15-4/3, Div 10-4/10, Div 20-4/24 May Div 22-5/1, Div 11 5/8, Div 18-5/15, Div 21-5/22, Div 5-5/29, Div 2-5/8s June Div 1-6/6, Div 2-6/12, Div 6-6/19, Div 3-6/5s July Div 3-7/2, Div 7-7/3. Div 8-7/31, Div 5-7/31s August Div 9-8/7, GTW-8/8, Div 15-8/14, Div 20-8/14s September Div 10-9/11, Div 20-9/25, Div 21- 9/11s October Div 11-10/9,Div 22-10/16, Div 18- 10/23 November Div 21-11/6 December 2013 Budget Carry-over revenue $5,000.00 $5,000.00 Prvider 1 $1,800.00 $1,800.00 Prvider 2 $1,000.00 Prvider 3 $500.00 $500.00 Prvider 4 $2,500.00 Prvider 5 $5,000.00 $5,000.00 Prvider 6 $30,000.00 $10,000.00 Prvider 7 Prvider 8 $2,000.00 $2,000.00 Prvider 9 Prvider 10 Prvider 11 $20,000.00 $20,000.00 Subtotal= $67,800.00 $28,800.00 $10,500.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Expense Account FY2013 Jan-13 Feb-13 Mar-13 Apr-13 May-13 Jun-13 Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Incen ve Programs $17,250.00 $100.00 $1,000.00 $4,000.00 $2,000.00 $300.00 $800.00 $1,500.00 $100.00 $1,000.00 $200.00 $500.00 $5,750.00 Health Fairs 00.000,3$00.000,3$00.000,3$00.000,3$00.000,3$00.000,3$00.000,81$ Program Supplies $2,400.00 $1,000.00 $100.00 $200.00 $100.00 $100.00 $100.00 $100.00 $200.00 $100.00 $100.00 $200.00 $100.00 Travel $1,200.00 $100.00 $100.00 $100.00 $100.00 $100.00 $100.00 $100.00 $100.00 $100.00 $100.00 $100.00 $100.00 Prinng and Copying 00.005$00.005$00.000,1$00.000,2$ Program Shirts 00.005,2$00.000,1$00.005,3$ Meeng $5,350.00 $350.00 $350.00 $350.00 $350.00 $350.00 $350.00 $350.00 $350.00 $350.00 $350.00 $350.00 $1,500.00 Subtotal= $49,700.00 $49,700.00 $3,550.00 $1,550.00 $7,650.00 $5,550.00 $4,350.00 $4,350.00 $5,050.00 $6,250.00 $2,050.00 $750.00 $1,150.00 $7,450.00 $18,100.00 ****not based on actual numbers Ambassadors Agreement Wellness Ambassador’s Role and Responsibilies • Assist in the implementaon and evaluaon of the worksite wellness program that include behavior change programs, incenve programs, health seminars, fitness challenges, special events, and intranet based programs, etc. • Update and maintain wellness bullen boards with promoonal literature. • Maintain the tracking and evaluaon systems for the worksite wellness program, which include HRAs, employee parcipaon, employee sasfacon, success stories, etc. • Become efficient at all intranet based data input tracking and reporng. • Develop and implement systems for communicang (including electronically) with parcipants in wellness and incenve programs and track the responses. • Communicate regularly with the Wellness Manager on the status of the program, parcipant concerns, and progress. • Facilitate health, fitness, and nutrion-related programs, either in group or individualized seng. • Coordinate contracted presenters and exercise leaders for health, fitness, and nutrion programs. • Coordinate distribuon of incenve program prizes. • Assist with the content and distribuon of newsleers and other communicaons materials. • Assist in the overseeing the fitness facility by supervising the exercise floor, serving the fitness center members, and ensuring a safe environment in which to exercise. • Provide fitness center orientaons of gym equipment to new members. • Perform cleaning and report preventave maintenance on fitness equipment on a scheduled basis. • All other dues that are directly related to the wellness program as instructed by the Wellness Manager. I have read and agree to the above stated terms and condions: _________________________________________________________ etaDdengiS ___________________________________________ Print Name Interest Survey Employee Wellness Interest Survey Thank you for completing this survey. Employee’s responses will provide us with the type of activities that are of interest to you. Your participation in this survey is voluntary. The information you provide will only be shared by the wellness committee in order to develop a program that benefits you. elaM elameF:redneG Age Group: 21-35 36-50 51-60 61+ Would you participate in any wellness activities if they were provided to you? oNseY Are you interested in being a part of a wellness committee or planning a wellness program and/or activities? Yes No If yes, please provide name and number: How would you prefer to receive communication regarding wellness (Choose 2): Bulletin Board Email Website Other Please list any specific health foods you would like added to our vending machines: As part of some wellness programs, other worksites offer books, videos, etc. as a library. Would you use this kind of resource center, if available? oNseY Indicate which of the below activities you would like offered within the next 12 months (choose top 6)and indicate what time of day you would like the activities/classes/screenings offered:

G -8 Interest Survey cont. Indicate which of the below activities you would like offered within the next 12 months (choose top 6) and indicate what time of day you would like the activities/classes/screenings offered: Acvies Check Box 7a-9a 10a -12p 1p-3p 4p-6p 7p-9p Ba ck Care and Heal th CPR/Fi rs t Aid Training Cancer Educa on Cardiova scul ar Hea lth Cholesterol /Blood Pressure Screening Diabetes Educa on Emo ona l Well ness Hea lth/Fi tness Educa on Nutri on/Heal thy Cooking Physical Educa on Classes Smoking Cessa on Stress Management Substance Abuse Awareness Time Management Weight Management Relaxa on Programs (medita on/yoga) Other____________________________ MTA-Division 3/28/2012 Percentage Tested 88.11cilotsaiD 08 < cilotsyS 021< lamitpO 92.31cilotsaiD 98-08 cilotsyS 921-021 neewteB noisnetrepyherP 54.7cilotsaiD 98-58 cilotsyS 931-031 neewteB noisnetrepyherP Hypertension 822.14cilotsaiD 99-09 cilotsyS 951-041 neewteB 1 egatS 311.91cilotsaiD 901-001 cilotsyS 971-061 neewteB 2 egatS 54.7cilotsaiD 011 cilotsyS 081 ot lauqe ro naht retaerG 3 egatS 86:detseT latoT MTA -Division Blood Pressure Screening Optimal <120 Systolic < 80 Diastolic Prehypertension Between 120-129 Systolic 80-89 Diastolic Prehypertension Between 130-139 Systolic 85-89 Diastolic Stage 1 Betw een 140-159 Systolic 90-99 Diastolic Stage 2 Betw een 160-179 Systolic 100-109 Diastolic Stage 3 Greater than or equal to 180 Systolic 110 Diastolic 5 / 7.4% 28 / 41.2% 13 / 19 1% 5 / 7.4% 9 / 13.2% 8 / 11.8% Getting Started-Seminars

G -9 Getting Started-Seminars Data Report Division A B C D E F G H I J K L M N O P Total Pop 620 575 574 592 86 696 521 679 655 209 688 624 344 129 105 2000 Actual 103 213 146 139 74 75 116 160 224 104 105 124 75 58 37 286 % 16% 37% 25% 23% 86% 10% 22% 23% 34% 49% 15% 15% 23% 44% 35% 14% Programs Tour De Sewer Revlon Run/Walk OCTA/MTA 10k ADA Walk 13 27 50 72 Programs Div Div Div Div Div Div Div Div Div Div Div Div Div Div Div Div 8 week 7 12 15 3 3 6 11 6 12 4 5 8 2 10 4 0 5k Challenge 026219278554342 Health Fairs Division Total Popula‡on Registra‡on #'s % AŠendance Completed Screenings % Screening Comple‡on Union A Union B Union C Union D Union E A 424 89 21% 72 80% 67 3 4 8 7 111502%1642%269336B 2 C 1500 228 15% 98 44% 25 7 7 5 71 D 512 80 15% 58 78% 68 3 1 3 0 912203%6614%572628E 6 Division A B C D E F G H I J K L M N O P Fitness 63 137 51 88 53 57 98 141 70 80 92 87 63 40 34 0 Wellness 74 118 121 97 38 72 143 54 184 78 57 68 25 25 20 286 resiaKnoitpircseDerusaeM Permanente So. CA Regional Average (2011 Q4) Your results (2009 Q4) Your results (2011 Q4) Percent of eligible members screened Cholesterol levels % of members with cholesterol levels > 200 36.9% 37.1% 33.7% 67.0% Blood pressure levels % of members with blood pressure >= 140/90 10.6% 16.3% 15.1% 77.3% Smoking rates % of members who smoke 11.6% 14.3% 14.1% 92.3% Overweight or obese-adults % of adult members with BMI > 25 71.7% 86.6% 84.2% 75.4% Overweight or obese-children % of child members with BMI > 25 36.7% 43.7% 44.6% 62.9% Kaiser Permanente Health Report Kaiser Permanente Periodic Utilization Report

G -10 UTU-MTA Trust Fund Rate Increase History 2009-2013 • Over the 5-year period 2009 – 2013, the UTU-MTA Trust Fund’s annual rate increase for Kaiser has averaged 7.0%, compared to Kaiser’s overall Southern California average of 7.4%. • The Trust Fund’s January 1, 2013 rate increase is 3.8%, compared to Kaiser’s overall average of 6.0%

G -11 INTRODUCTION: London Transit has the responsibility to provide its passengers with an efficient, safe, convenient and attractive Transit system. As an employee, you share these responsibilities and therefore have an obligation to yourself, the public you serve and to London Transit to provide the best possible service to our customers. In order to help each employee in achieving these goals, the following Guidelines have been prepared so that operators may know what is expected of them and help to ensure that London Transit operates in a reliable, efficient, consistent , effective and safe manner. This manual of safe operating guidelines for drivers provides a framework to guide our day-to-day activities. No document can possibly describe rules, regulations, or procedures to cover every eventuality. However, it can provide a solid foundation and reference for the way we do business. At London Transit the following guiding principles should serve as a checklist to help us continuously improve. They also are an indicator of the spirit and intent in which these operating guidelines were developed. 1. SAFETY FIRST; 2. TREAT PEOPLE WITH DIGNITY AND RESPECT; 3. EXCEL IN CUSTOMER SERVICE; 4. WE WORK AS A TEAM. We have an absolute commitment to the safety of our employees and customers. Every reasonable effort must be made to ensure that employees, customers and the public are not placed needlessly at risk. No matter what the circumstances, everyone deserves to be treated with dignity and respect. Our constant interaction with others can, at times, test our patience, understanding and people skills. Remember that almost every situation can be diffused and resolved if you remain calm, clear-thinking and open-minded. Our performance is measured by the extras that we do. Greet customers, give directions and provide assistance. Always put your best foot forward. As Professionals, we are all committed to providing the best public transit service to our customers and the people of London.

G -12 FIRE ON THE BUS: THE SAFETY OF THE OPERATOR AND CUSTOMERS IS THE FIRST CONSIDERATION WHEN A FIRE OCCURS. Open all doors to permit everyone to alight and lead people to a safe location away from the vehicle and any other hazards (traffic, etc.) Attempt to extinguish the fire with the extinguisher, IF IT IS SAFE TO DO SO. Never ever turn your back on a fire or place yourself in a dangerous position. Notify dispatch by radio or by telephone giving the exact location of the bus.. Note: It is the responsibility of every Operator to know the location of the Fire Extinguisher on all models of buses operated by London Transit. The location is labelled. All Natural Gas buses are equipped with an automatic engine compartment fire suppression system that can be manually activated by the Operator. The manual activation control is located in the driver’s compartment area. It is the responsibility of every Operator to be familiar with the fire suppression system and use of the manual control. Operators must also be familiar with the manual (emergency) operation of all doors, ramps on low floor buses and opening of windows for emergency escape. If your extinguisher has been used for a fire, report this to dispatch and leave the expended extinguisher on the floor of the bus near the fare box so that the extinguisher is replaced before the vehicle goes out again. Ensure that you report this fact when you return the bus to the garage. EMERGENCY EVACUATION: In any emergency situation, it is the responsibility of the Operator to give every possible assistance to every customer. Therefore, the Operator must conduct himself/herself in a calm and controlled manner. The following events will involve the emergency evacuation of a vehicle: (a) bus on fire; (b) serious accident; (c) odour of natural gas (on natural gas vehicles); (d) bus stalled in a dangerous position (on railway tracks, the crest of a hill, sharp bend etc.) (e) any unusual situation where evacuating the bus would be advisable. Evacuation Procedure: 1. Open both the front and rear doors. Request in a clear voice, that all customers leave the bus and stand well clear. If necessary, use emergency procedure to open the doors. 2. On low floor buses, Operators will be required to deploy the ramp if a person using a wheelchair/scooter is onboard or enlist the aid of other passengers to assist in removing the disabled person. 3. If the door(s) will not open advise customers that the side windows can be pushed out at the bottom of the frame. If the bus is equipped with a roof hatch, it can also be pushed out. 4. After all passengers have been evacuated and led to a safe location, the Operator must move the bus to a safe location. PROVIDED IT IS SAFE TO DO SO. If the doors will not close and the interlock brakes are activated, place the door master switch in the “OFF” position. This will permit the bus to be moved.

G -13 PERSONAL SAFETY: Bus Seats: It is important that seats are adjusted using proper procedures and employing ergonomic principles. Properly adjusted seats offer a safe and comfortable ride. London Transit uses two distinct seats for their vehicles and adjustment procedures are available for both the Recaro and Ergo Metro seats. Please insure that the seats are adjusted each and every time. Adjustment procedures are provided later in this guide. Please refer to the appropriate diagrams. Wearing of Seat Belts: Operators of buses are not exempt from wearing seat belts. THEY MUST BE WORN BECAUSE IT IS THE LAW! (Highway Traffic Act Section 106) Steering: At all times it should be palms down, fingers wrapped around the steering wheel, thumbs on top, unless in a full turn. Operators must not rest hands or elbows on the spokes or the center portion of the steering wheel or drive with one hand on the farebox. All turns must be completed employing over hand or push-pull techniques. Garage Floors: Walk careful and DO NOT RUN in the garages – watch for moving buses and water or oil on the floor. Report any spills or unsafe conditions to a supervisor immediately. Slip and Falls Hazards: Slips and falls are still a common – and serious source of workplace injury. Awareness of the hazards, and keeping to good practices, can help to minimise the slip and fall hazards that you could face. On entering/leaving the bus, walk don’t run and make use of the handrails. Do not carry items that will obstruct your view and be aware of all objects that could cause a needless injury. A slip or a fall is unlikely if you are in your usual work environment and everything is in its place. Make a change in that workplace, and you invite a fall. For example, unexpected litter, improperly stored materials, or oily or wet patches on the stairs or walking surface floor are sure to invite a fall. Be on the lookout for debris, oil, water, or other hazards. Get them cleaned up before an accident does happen. Walk where you’re supposed to walk. Watch where you’re going; don’t be distracted by conversations. Walking around in the dark or in an area with poor lighting is asking for a fall. Wear appropriate footwear – shoes with non-skid soles and rubber heels that are in good condition. Winter Hazards: We must keep in mind that falls occur more frequently during the winter months due to the adverse weather conditions. When exposed to these conditions, remember to be extra cautious, be sure of footing and wear proper footwear.

G -14 Universal Precautions: Blood, certain body fluids and sharp objects are considered to be potentially infectious and handling them must be avoided whenever possible. If exposed, avoid hand to mouth/eye contact and wash hands as soon as possible. Although most secretions such as sweat, tears, urine, feces and vomit are not infectious (unless visible blood is present) operators are instructed to avoid contact with them. If a customer vomits on the bus or has an “accident” resulting in urine or feces on the floor or seats of the bus, keep others away from the infected area and cover the waste with paper towels. Notify dispatch immediately for further instructions and a bus change off. ADJUST PROCEDURES FOR RECARO SEATS:

G -15 ADJUSTMENT PROCEDURES FOR ERGO METRO SEATS: . DEFENSIVE DRIVING: What is a defensive driver? A defensive driver is one who allows for the lack of skill and knowledge on the part of the other driver, who recognizes that he/she has no control over the unpredictable actions of other drivers and pedestrians or control over conditions of weather and road and who therefore, develops a defence against all these hazards. He/she concedes the right-of-way and makes other concessions to avoid a collision. He/she is careful to commit no driving error him/herself and is defensively alert to avoid traps and hazards created by weather, roads, pedestrians and other drivers. DEFENSIVE DRIVING TECHNIQUES: Cushion of Safety in Front of Vehicle: The front of the vehicle is a critical area for an operator to manage: Operators need to scan long distances in front of the vehicle, maintain a proper following distance, and stay out of other driver's BLIND spots. Allow adequate stopping distance between you and the vehicle you are following! Adequate stopping distance will depend on the type of vehicle, road and weather conditions.

G -16 Dealing with intersections: Intersections present a significant risk to drivers. A substantial number of multi-vehicle accidents occur at intersections and therefore special attention must be paid. Here are some suggestions and tips: Stop far enough back that you can see the rear tires of the vehicle in front of you. Keep wheels straight when stopped to turn left. Keep out of crosswalk zones. Cover brake when approaching a green light. Do not leave enough room on right for another vehicle to squeeze by. Operation Sit Fit Introduction In spring 2004, London Transit Commission worked with The Spine & Joint Physiotherapy Centre to deliver a training program, Operation Sit Fit for all drivers. The goal of Operation Sit Fit is to ensure all drivers are trained on proper posture at work to assist in decreased injuries and a better quality of work life. The job of a bus driver is repetitious and at times requires awkward body positions. Daily exercises are important to maintain flexibility and core strength. Understanding your body, exercising to maintain strength and flexibility as well as proper posture at work is the key. Use your body to your advantage to create strong supporting muscles and flexible joints. These are important for a healthy spine. Be conscious about: Choosing body positions that ensure less strain on joints and muscles. Minimizing muscle contraction. Minimizing tension on capsule and ligament. Providing maximum strength by using muscles at optimal length. Working in the ‘neutral’ zone (a comfortable, easy zone that does not put strain on joints and tissues). Tips to Remember When Completing the Daily Tasks of Bus Driving Outlined on the next few pages we have outlined some of the main functions in a driver’s day, visual cues to make you more aware of your posture, and some suggestions on how to improve your posture and use your body to its best advantage. Sitting and Adjusting the Seat Ensure the seat height, depth back support and vertical tilt are adjusted to your body type. Ensure lumbar support is adjusted.

G -17 During the day, re-adjust the chair to change pressure points and alter muscle use. Use core muscles while sitting and driving to protect your low back. At the terminal point, stand-up and stretch. (See exercises Reversal Lumbar Extension). SEAT ADJUSTMENT CORRECT INCORRECT Driving in Bad Road Conditions Ensure seat is adjusted properly if moving forward in the chair. Take extra stretch breaks (especially the neck). Avoid over gripping the wheel which will cause static muscle work DRIVING IN POOR WEATHER CORRECT INCORRECT Changing the Destination Signs When changing the destination sign, move as close as possible to the switch to avoid over reaching. Use proper reaching techniques. Use core muscles (shoulder blades down and together and use stomach muscles). Avoid twisting the spine. CHANGING LOCATION DESTINATION CORRECT INCORRECT Opening and Closing the Doors Manually When opening and closing the door manually use your body to your advantage. Use proper reaching techniques. Ensure that your shoulder is in the neutral ‘easy’ zone. When pushing use stomach muscles and core stability muscles. As the door opens, move with the door to avoid over reaching.

G -18 DOOR OPENING CORRECT INCORRECT Adjusting the Outside Mirrors When adjusting the outside mirrors use the proper device to complete this task. Avoid over reaching Keep elbows tucked into side Watch out not to arch or extend at the low back when working above shoulder height ADJUSTING MIRRORS OUTSIDE CORRECT INCORRECT Steering Ensure steering wheel (if adjustable) is adjusted to maintain neutral postures. Ensure hand position allows for neutral postures of the wrist and shoulder. Take breaks and stretch during the day Avoid over-gripping the wheel which will cause static muscle work. Avoid resting on the fare box. Ensure proper clothing on a cold or warm day. Avoid hand or hand when turning, over-reaching and impingement zones. Use shuffle method when turning. HAND POSITION ON STEERING WHEEL CORRECT INCORRECT Lifting Ramps Lifting with your knees slightly bent and your back straight. Avoid twisting. Avoid accessory muscle use. Do not hold your breath. The form should be smooth and controlled. Use your stomach muscles to protect your back.

G -19 LIFTING RAMPS CORRECT INCORRECT Opening and Closing the Windows Move body as close as possible to the levers. Ensure the window is not stuck before applying great force. Use core muscles (shoulder blades down and together and use stomach muscles). Try to work in as close to neutral zone as possible. OPENING WINDOWS CORRECT INCORRECT DRIVING POSTURE “DON’T” DON’T REST ARMS ON STEERING WHEEL DON’T OVER REACH WITH TURNING DON’T LEAN ON FARE BOX DON’T HIT KNEE ON FARE BOX DRIVING POSTURE “DO’S” DO PULL TRANSFERS TOWARDS YOU DO USE THE HEAD REST

G -20 DO WATCH YOURSELF AT FARE BOX DO ASSIST PATRONS WITH CARE DO GRIP WITH LOOSE GRIP DO TURN WITH SHUFFLE METHOD On the Job Exercises How to Stretch Hold stretch 10-20 seconds. Breathe when stretching. Focus on the muscle being stretched and feel the tension release. When to Stretch At a stoplight. When changing the bus signs. At the terminal point. When stepping out of the bus for fresh air. At the end of the day. 1. Sit up tall. 2. Push chin in towards chest. 3. Feel stretch in upper neck (headache zone). 4. Hold 10 seconds and repeat 3 times. 1. Hands on wall (make sure back heel remains on floor). Lean forward. 2. Feel stretch in back lower leg. 3. Hold 20 seconds and repeat 2 times.

G -21 1. Hold left wrist and then right wrist as shown, making sure to keep fingers straight. 2. Bend the wrist and fingers upward until you feel a stretch. 3. Hold 10 seconds. 4. 3 repetitions each hand. 1. Reach downward with right hand and then left hand. 2. Now use other hand to bend neck in opposite direction as shown, until you feel a gentle stretch. 3. Hold 10 seconds. 4. 3 repetitions with each hand. 1. Place hands firmly against hips as shown. 2. Bend backwards until you feel a stretch. 3. Hold 5-10 seconds. 4. 5 repetitions. 1. Standing up straight, place one leg forward and keep your supporting back leg slightly bent. Lean forward towards your forward foot, bending from the hips. 2. Hold for 20 seconds, alternate legs, i l More helpful exercises for London Transit Drivers Wrist Hold wrist as shown. Make sure to keep fingers straight. Bend wrist and fingers upward until you feel a stretch. Hold for 20 seconds and repeat 3 times. Shoulders and Upper Back Stand up tall. Clasp hands. Lift both arms up and over your head. Lean back (to avoid bending at your low back you may want to do this exercise while sitting with your feet up on a stool). Hold for 2-3 seconds then repeat 5 times. Grip left hand on right elbow. Pull arm across chest. Feel the stretch at the right upper back. Hold 20 seconds, and then repeat with left arm.

G -22 Lower Neck Right hand behind back, neck looks to left armpit. Gently pull neck towards left armpit. Feel stretch on right side of neck. Upper Neck Sit up tall. Push chin in towards chest. Feel stretch in upper neck (headache zone). Hold 10 seconds and repeat 3 times. Lower Legs - Quadriceps Grab your left ankle from behind with your left hand and pull your foot/ankle slowly toward your buttocks. Hold it there for 20 seconds then rest. Alternate between legs and repeat 3 times for each leg. Hamstrings Standing up straight, place one leg forward and keep your supporting back leg slightly bent. Lean forward towards your forward foot, keeping your back straight and bending from the hips. Hold that position for 20 seconds. Then alternate legs and repeat 3 times per leg. Hands on wall (make sure back heel remains on floor). Lean forward. Feel stretch in back lower leg. Hold 20 seconds, and then repeat 2 times. Chest Stand in doorway. Put hands on either side of doorway. Lean into doorway. Feel stretch in chest. Hold 20 seconds, and repeat 3 times

G -23 Low Back Hands on buttocks. Lean back to extend low back. Hold 2-3 seconds and repeat 5 times. VIOLENCE IN THE WORKPLACE We live in a world where hostile or even violent interactions occur with what seems like increasing frequency. The trend is certainly prevalent in all occupations dealing with the public. There are many factors that effect how particular interactions will end up, and management at LTC and ATU Local 741 have worked together to try and develop solutions to deal with several of these factors. The solutions include engineering controls (for example the AVL system, radio and emergency communications equipment), administrative controls (for example, special emergency protocols worked out with Police) and employee actions based on training and experience. In many cases the most important factor is the manner in which the employee deals with the situation. The video, which was developed by a team including both management and union personnel, presents two scenarios which depict an Operator dealing with typical issues that emerge in service. The video incorporates information from two sources. The first is a program called Tactical Communication. London Police Services developed “Tactical Communication” or TAC-COM to provide skills to officers when dealing with the public. The second is a program developed by Rutgers University called Violence in the Transit Workplace – Prevention, Response, Recovery. LTC has adopted the information from both programs in developing the video. We encourage employees to view the video, read this brochure, think about the concepts, discuss them with others and apply them in situations that arise during work. “TAC-COM” is defined as the principles and techniques of communication used by the person charged with the responsibility of being the problem-solver. There are three objectives in applying the principles of “TAC-COM”. There are: To ensure a standard and professional approach to all interactions with transit customers and the public; To prevent conflicts from escalating; and De-escalation of a conflict that is already in progress. The first objective of “TAC-COM” is to ensure a standard and professional approach in all interactions with transit customers and the public. So whether it is a normal, regular passenger interaction or a protection confrontational situation, “TAC-COM” strategies will help you ensure a consistent approach, and when used by all Operators set a standard right across the system. This does not mean you must speak

G -24with everyone who steps onto your bus, but you can communicate without speaking, for example by making eye contact and smiling. We all have different skill sets and maintain order on our bus in our own way, but the “TAC-COM” tools will help us all be consistent with our interactions. Another key concept on which the video is based is the concept of assessing the situation and behaviors as falling into one of three categories – different, difficult and dangerous. An example of different behavior is a homeless person who rides your bus and mutters profanities to himself. Another example is shown in the video, where a rider fails to make eye contact or to show his pass appropriately when boarding. Difficult behavior is usually angry or hostile behavior, such as profanity directed at an Operator. The potential for violence has escalated. Physical signs of escalated behavior include: Red face, rapid breathing Glaring or avoiding eye contact Tight body language – crossed arms or legs or clenched fists. The key is to prevent this behavior from escalating, for example from difficult into a dangerous situation where violence/harm is likely to occur. The video depicts two difficult situations, and the use by the Operator of a variety of skills and techniques to prevent the situation from escalating into a potentially dangerous one. Of course, in a dangerous situation the most important thing is safety of all involved, and whenever a situation has (despite all efforts) escalated to a dangerous situation, it will be important for the Operator to follow emergency protocols to get assistance. One of the key outcomes of “TAC-COM” is the preservation of the dignity of all involved. If you are able to do this successfully, then most situations will be in your control. In order to preserve the dignity of all involved parties, it often means you, as the person charged with responsibility, must take the higher ground and not focus on making the customer wrong and you right. It is critical that you remember that you as an individual Operator can not change other people’s behavior. You’ll see examples of that in the video. Self control is important; you’ll know when you need to exercise self control when you, for example, feel your anger rising – all Operators have experienced the need to “count to three” the way the Operator does in the second scenario. Self control can be developed by a technique called “self-talk”. This means when under pressure, taking the time to say to yourself phrases such as “I’m not going to sink to that level”. Components of Communication Studies show that communication is made up of three components: the actual words we use, the way we say them, and our body language while saying them (with studies suggesting that 70 of the message is contained in the body language!). All three are important. Also think about the length of time you take to respond to comments. People generally expect a response or acknowledgement to a question within 2-3 seconds. By not waiting long enough, you could bring on some anxiety that may escalate the situation. Patience will often pay big dividends. On the other hand, by not responding in a timely fashion to a customer’s question, you may cause them to become irritated and angry. Due to the repetitive nature of a bus operator’s position, you have to remember that even if it’s the `00th time you’ve been asked a particular question that day, it’s not the 100th time that person has asked you. Another technique of communication is empathetic listening. Key words which accomplish this task should become part of the bus operator’s language. For example, “I appreciate that”, “I understand that” and “Maybe so”… these are all effective empathy statements. Empathetic listening also includes resisting the urge to over-talk the issue, and being prepared to repeat yourself, patiently – you may have to restate your position without raising your voice or increasing your intensity. Verbal Communication Positive language stresses what CAN be done, suggests alternatives and choices and focuses on positive outcomes to situation. A very important strategy which an Operator can use with a difficult rider is to offer choices and consequences, both positive and negative. As an example, when you look at scenario 1 in the video, suppose that the rider refused to surrender the monthly pass portion. The Operator then could offer choices and consequences. The Operator might say “If you surrender the pass, we can continue on the trip and I can get you and the other passengers to where they’re going on time. You would always have the option of contacting our Customer Service line afterwards if you wanted to discuss that further. On the other hand, if you choose not to surrender the pass, I’m going to have to follow our procedures and wait for my Supervisor to arrive.” When a confrontation begins escalating, it may be necessary to disengage, and it takes really good judgment to know when that is appropriate. Appropriate disengaging could mean in some cases ignoring the individual or not participating in their emotional or irrational behavior – don’t given them an audience. It’s all in the way you get your message

G -25 across – just saying something the wrong way may cause escalation. Ensue that you don’t given commends – “Get off this bus!” or that you back yourself into a corner with no way out if challenged. In terms of body language, consider the following: Eye Contact – Eye contact is an important communications tool. Generally, eye contact is held for 3 seconds or less. Eye contact with other drivers on the road is an important elements in defensive driving and lets them know you know they are there, and the same principle applies with passengers when board. Glancing in the rear view mirror is an important tool…it conveys the message: ‘I know you’re here and what’s going on”. Regularly glancing in the rear view mirror, as the Operator does in the video, also calms other passengers by letting them know that you are aware of what is going on. On the flip-side, staring can be perceived as a form of aggression. Facial expressions – try to keep these neutral; often this will automatically occur if you moderate the tone of your voice. Touching – Company policy does not permit bus operators’ to touch customers, except in situations where it may be necessary for a bus operator to secure a wheelchair passenger or in assisting a passenger. When it is necessary to touch a passenger, permission should be verbally requested by the Operator before the motion is made. The following are some do’s and don’t if you observe the non-verbal clues of escalation noted above: DO’s Remain calm Stay neutral Show respect (whether or not you feel its deserved) Give appropriate space (see below on “distances”) Remember your top priority is safety DON’T Over react such as yelling See the situation as a power struggle Take sides if you can help it Send aggressive body language, confine the individual Look to teach the person a lesson Distances As a bus operator, you are generally in a seated position, which means extra preparation and thought must be given to maintain your safety and the safety of others. When considering appropriate distances, there are three main types of ranges: Social distance – this would be our typical customer interaction – as they board, pay the fare, exchange transfers and ask typical questions related to schedules, directions and so forth. It is defined as about an arm’s length distance. Violation of someone’s space can cause feelings of anxiety. It can cause some to become very defensive of their space, in fact some may lash out physically to defend it. Often, the beginning of a confrontation starts when one party physically closes in on another party’s personal space. Note on the video, scenario 1, the first time through the non-verbal as well as verbal communication and distances – although the actions may be exaggerated on behalf of the Operator, they demonstrate the principles. Communication distance – used when we’re communicating in an official capacity – our message may or may not be welcomed. We “project authority” – for example when communicating this way. This also a reasonable distance to consider while communicating with an aggressive or defiant individual – it offers you protection or warning of a hand/fist assault or kick. A 6’ distance is the ideal, but when you are in a seated position, it is sometimes difficult to achieve. Weapons Present Distance – the presentation of a weapon should have a dramatic effect on the distance you place between you and the armed offender. As soon as feasibly possible, the police recommend a distance of 25 feet between you and the offender. When you have reason to believe a weapon is present, do not try to guess if the offender is serious or not. Initiate emergency protocols through Dispatch at the earliest possible opportunity.

G-26 What to do if using these skills and techniques doesn’t de-escalate the situation sometimes, despite your best efforts, you may be unable to de- escalate the situation. If an operator is unsuccessful in de-escalating the situation, and has therefore lost control of the situation, assistance from an Inspector is required. It now becomes the role of the Inspector to de- escalate the situation. While you hope to never experience a physical confrontation with an individual, if you do, your safety becomes paramount. Here are some things Operators can consider if involved in a physical confrontation: Stand sideway – this limits the amount of exposed body mass; Keep your chin tucked in and down to protect yourself; Never turn your back on an inflamed individual – if you have walked through the bus to speak to an individual, walk backwards away from them; and finally; Use nearby objects for protection – look around, what is immediately available? A purse, lunch-pail or coat could all offer you some protection from attack. Conclusion: The application of “TAC-COM” and the other skills and techniques noted have many benefits. They allow you to have greater control over situations and help ensure a professional approach when dealing with the riding passengers and the public at large. They can help you reduce your job stress because successful conflict avoidance can make your working day, and the ride for your passengers, a lot smoother. Conflict, to some degree, is a part of everyday life. How you respond to conflict can make it disappear or contribute to making it grow. Remember to preserve the dignity of all involved parties by not focusing on being right and making the customer wrong. Give some thought to incorporating these skills into the way you handle situation that arise; we hope they help you deal effectively with them.

G -27

G-28 Ergonomic Checklist for Coach Operators Employee Name: Badge: Base: Date: Evaluator: Badge: Date: Is seat is pushed back when getting IN? Yes No OUT? Yes No Does the seat height, angle and backrest adjustments Yes No place the ears shoulders and hips in a straight line? Explain if “No” Does the seat back support the upper back and lumbar area Yes No Explain if “No” Are the shoulders relaxed? Yes No Are the elbows close to the sides with shoulders relaxed? Yes No Does the view of the mirrors on board and on the exterior Yes No prevent muscle strain of the neck? Are the thighs parallel to the floor? Yes No Are the hips at a 900 angle or slightly open? Yes No Explain if “No” Are the pedals at comfortable angles? Yes No Explain if “No”

G-29 Is the sole of the foot in contact with the pedals? Yes No Explain if “No” Are the foot control switches at a comfortable level? Yes No Explain if “No” Are the wrists straight and in neutral position when steering? Yes No Most common form of steering Shuffle Hand over Hand When executing hand over hand steering, is the upper back and Yes No lumbar supported by the seat? Shoes are black non-skid sole Yes No Heel of shoes does not exceed two inches Yes No Employee can see clearly, eye examination within the last two Yes No years. Employee practices the micro stretch breaks learned in ART Yes No and/or SCOT. Employee takes active breaks rather than staying seated on Yes No layovers or between shifts. A “No” response is considered undesirable, indicating that improvements need to be recommended and implemented. Demonstrate body mechanics for securing a Wheelchair. A full evaluation will be required to observe body mechanics, body angle, pushing, pulling, reaching and bending. This document has been reviewed with me at the time of the evaluation and I understand the information that has been reviewed during this workstation evaluation. Coach Operator Signature: Badge: Evaluator Signature: Badge:

H-1 Sleep Disturbance and Sleep Apnea for Transit Drivers A P P E N D I X H

H-2 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.0 One in 12 Scottish bus operators studied reported falling asleep at the wheel at least once a month.1 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. 2 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.3 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, eight 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? 4 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.

H-3 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 eight 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 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. 5 You may have heard that exercising is not recommended 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. 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 health6 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 consistently 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/) TCRP Report 81 Toolbox for Transit Operator Fatigue onlinepubs.trb.org/onlinepubs/tcrp/tcrp_rpt_81.pdf NIH Your Guide to Healthy Sleep Funded by Transportation Cooperative Research Program F-17. Additional Transit Health Protection and Promotion materials at http://www.trb.org/TCRP/TCRP.aspx and Transportcenter.org 0 Martins, R. C., Andersen, M. L., & 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. 1 Vennelle, M., H. M. Engleman, et al. (2010). "Sleepiness and sleep-related accidents in commercial bus drivers." Sleep Breath 14(1): 39-42. 2 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 3 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. 4 Adapted from NIOSH http://blogs.cdc.gov/niosh-science-blog/2012/03/sleep-and-work/ last updated 12.8.2012 5 http://www.sleepfoundation.org/alert/national-sleep-foundation-poll-finds-exercise-key-good-sleep 6 Adapted from NIH Your Guide to Healthy Sleep

Abbreviations and acronyms used without definitions in TRB publications: A4A Airlines for America AAAE American Association of Airport Executives AASHO American Association of State Highway Officials AASHTO American Association of State Highway and Transportation Officials ACI–NA Airports Council International–North America ACRP Airport Cooperative Research Program ADA Americans with Disabilities Act APTA American Public Transportation Association ASCE American Society of Civil Engineers ASME American Society of Mechanical Engineers ASTM American Society for Testing and Materials ATA American Trucking Associations CTAA Community Transportation Association of America CTBSSP Commercial Truck and Bus Safety Synthesis Program DHS Department of Homeland Security DOE Department of Energy EPA Environmental Protection Agency FAA Federal Aviation Administration FHWA Federal Highway Administration FMCSA Federal Motor Carrier Safety Administration FRA Federal Railroad Administration FTA Federal Transit Administration HMCRP Hazardous Materials Cooperative Research Program IEEE Institute of Electrical and Electronics Engineers ISTEA Intermodal Surface Transportation Efficiency Act of 1991 ITE Institute of Transportation Engineers MAP-21 Moving Ahead for Progress in the 21st Century Act (2012) NASA National Aeronautics and Space Administration NASAO National Association of State Aviation Officials NCFRP National Cooperative Freight Research Program NCHRP National Cooperative Highway Research Program NHTSA National Highway Traffic Safety Administration NTSB National Transportation Safety Board PHMSA Pipeline and Hazardous Materials Safety Administration RITA Research and Innovative Technology Administration SAE Society of Automotive Engineers SAFETEA-LU Safe, Accountable, Flexible, Efficient Transportation Equity Act: A Legacy for Users (2005) TCRP Transit Cooperative Research Program TEA-21 Transportation Equity Act for the 21st Century (1998) TRB Transportation Research Board TSA Transportation Security Administration U.S.DOT United States Department of Transportation

Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention Get This Book
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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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