Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line (2020)

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102 8.1 Overview The objective of this study was to identify ways to improve employee health and safety outcomes resulting from work conditions and broader health promotion practices and the corresponding impacts on the bottom line. The project team’s research focused on the preva­ lence of conditions, costs associated with conditions, and statistical analysis of data on participa­ tion in and results of health and wellness promotion programs. This report adds another layer of research to past studies that have explored health and safety outcomes for transit workers and health promotion programs. This report quantifies the costs of widespread and consis­ tently poor health and safety outcomes and the cost savings, if any, of health promotion programs. Dangerous and strenuous work environments exact a toll on workers that affects their employers and society. A better understanding of that toll, its costs, and the potential means of mitigating it are an important research pursuit. The research for this project began with an in­depth review of the literature to better understand the position of transit workers in relation to health and safety programs, the general effectiveness of such programs, and the specific health and safety issues that are most prevalent and costly among transit workers. The research approach was designed to respond to specific questions, and the substantive work used extant data to explore in­depth the issues of the prevalence and costs of health conditions, as detailed in Chapter 4 of this report. Chapter 5 covers an extension of that work, presenting estimates of the costs to employers, society, and individual transit workers. In both analyses, transit workers’ costs were compared to those of the general worker population to get a sense of the “excess” health and safety costs associated with transit work. In general, most condition prevalence rates and costs were found to be higher for transit workers (without holding other factors constant, such as age, sex, or race). In the literature review, the project team explored issues linked to health and safety out­ comes and costs as they relate to workforce conditions, as well as programs used to mitigate negative health and safety outcomes. Where possible, evidence of the cost­effectiveness of such programs was reviewed, and the project team found that several factors faced by transit workers affect the health and safety of operators. These factors include, but are not limited to, the following: 1. Urinary tract problems that arise as a result of limited access to restrooms, 2. Musculoskeletal injuries resulting from prolonged sitting and repetitive motion, 3. Safety factors linked to actions by other drivers and unruly passengers, and 4. Access to food alternatives and fitness centers due to long, irregular, and split shifts. C H A P T E R 8 Conclusions

Conclusions 103 For non­operators, exposure to exhaust fumes and other automotive chemicals are also risk factors for poor health. The literature also has documented worker stress and fatigue as health and safety issues. Recognizing that transit workers experience these factors disproportionately helps us understand the differential costs that affect this population. The literature provides evidence of the direct costs of chronic health conditions, including absenteeism and turnover, and how wellness intervention programs function to mitigate these costs. Relatively few studies measure the indirect costs of occupational health injuries for transit workers, however, and limited data are available that provide evidence for the effectiveness of wellness inter vention programs for the transit worker population. The literature is largely inconclusive on the effectiveness of wellness programs to reduce costs in general and specifically for transit agencies. Most programs are not well supported, funded, or targeted to the unique challenges transit workers face. The project team also assessed the prevalence rates for the most common health condi­ tions for transit workers, the costs associated with those conditions, and additional medical expenditures. Most transit workers (72%) are involved in vehicle operations. Of these workers, just over 50% are bus operators. Most transit workers are male (63%), over 45 years of age (66%), and White (63%). Although the majority of workers in the transit industry are White, the percentage of Black workers is higher in the transit industry (29%) than in the general workforce (12%). Women, however, are underrepresented in the transit industry, making up 37% of transit workers but 47% of the overall workforce. The most common health conditions associated with transit workers are cardiovascular disease, hypertension, diabetes, musculoskeletal disorders, mental health, and respiratory condi­ tions (e.g., COPD, asthma). Further, it was found that rates of smoking and obesity were higher in the transit worker population than in the general population. The costs of each of these conditions were estimated by drawing on available information from journal articles and other sources. After establishing prevalence rates and the associated costs for the most common health conditions, the costs and rates of those conditions for transit workers were compared with those of the general population. The costs for transit workers were found to be consis­ tently higher than those for the general worker population, reaching as high as millions of dollars, though it is important to note that the costs associated with treating each condition are not necessarily additive because of comorbidities. The findings suggest that available resources might be most effective if allocated toward the prevention of these conditions. The result would likely be a lessening of programmatic costs of responding to transit worker health problems. Average annual expenditures and prevalence rates were used to estimate per­condition costs. Costs of average annual costs to workers from injury and death were estimated, as were the costs to employers and society in the categories of injury, death, absenteeism, workers’ compensation, disability (SSDI), disability (SSI), and Medicare. The method used for this research compared the costs for individuals in the transit sector with the costs for the general worker population and calculated the “excess” costs associated with transit work. In all cases, the project team found that the transportation/transit sector saw higher costs to workers, employers, and society in each cost category as related to the general worker population. Monetized esti­ mates of the costs linked to health risks and conditions faced by transit workers were presented, and elevated costs for transit workers and agencies were highlighted. The elevated costs point to areas where health and wellness programs may improve the health conditions of workers, thus reducing costs across multiple categories. Further improvements in on­the­job safety may decrease disability and injury costs. The costs estimated for this study were not an exhaustive list of employer and societal costs; many additional costs could not be itemized, such as quality of service. It is important to note that the cost categories overlap and are not additive.

104 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line The project team also conducted five in­depth case studies on health and wellness programs provided by transit agencies. The case studies provided the project team an opportunity to: • Learn about the types of programs provided to transit workers; • Examine the potential impacts of existing programs; • Identify what health and safety issues were addressed in each program; and • Examine how those issues aligned with the issues that had been uncovered in the literature review and analysis of secondary data. In most cases, the programs addressed several of the key issues faced by transit workers, including cardiovascular health, fitness (exercise), access to healthy food, diabetes, stress, and smoking. For the five cases examined, the details of program startup, organization, activities, resources, and participation were documented over time. In four of the case studies, individual­level data were available that enabled the project team to develop descriptive statistics and perform econometric regression modeling. Most of the programs had a weak relationship or no demonstrable relationship with the outcomes of interest (absenteeism and workers’ compensation claims). Nevertheless, these data provided a host of new information about participation in wellness programs and their potential for developing strategies to improve the health of transit workers. The project team’s analysis found no statistically significant associations with the programs and the outcome measures except for the DART wellness program, for which the project team found participation in the program had decreased the total number of absent hours. This result was based on a small sample, however, and should be interpreted with caution. 8.2 Key Findings The project team found that the most prevalent chronic conditions in the transit worker population are cardiovascular disease, hypertension, diabetes, musculoskeletal disorders, mental health, and respiratory illnesses. These six chronic conditions are the ones of greatest concern, however, and are found at much higher prevalence rates for transit workers than for the general worker population. Transit workers also suffer from other health conditions that may be related to their work, including hearing loss, bladder conditions, and cancer. Smoking and obesity also disproportionately affect transit workers. The case studies showed that programs often focus on obesity, offering increased and more diverse food choices and exercise programs. The programs examined also offer check­ins with nurses and health screenings, which could potentially identify diabetes and other potential health issues earlier. Only one program was found in which the relationship between partici­ pation and lower absentee hours resulted in statistical significance, though the sample size was small and the project team hesitated to draw conclusions based on a single finding. The literature review suggests that the health and wellness programs that transit agencies design should focus on problems caused by limited bathroom access, split shifts, and sustained sitting, rather than on exercise and weight loss, which are more typical. Changes that could improve safety include providing enhanced rest opportunities before and after shifts. Some of the agencies studied provided healthy snacks, which could benefit operators who may have difficulty accessing healthy foods before and after their shifts. Working to create more comfort able seating for operators would also be helpful, though it would take a large invest­ ment of resources over a sustained period. The most common problem, cited by agencies and labor and further underscored by claims data, is hypertension. Following hypertension, diabetes, musculoskeletal disorders, and weight

Conclusions 105 management were identified as the next most common problems. Some programs had elements that addressed these issues, such as health assessments, exercise programs, and nutrition classes. Unfortunately, it was not possible to measure changes in health outcomes based on program elements directly, although the project team did try to relate the program activities to outcomes that were part of an agency’s “bottom line.” The lack of data measuring the objectives of the programs is an area that could be improved by linking individual parti­ cipation in programs to outcomes based on the participants’ health records or self­reports. These types of evaluations would have to control for confounding factors, such as age. It was difficult to identify a direct impact of health and wellness programs on measurable outcomes such as absenteeism or annual number of medical claims. None of the analyses of individual­level data from the case studies had strong results. A significant result was found at one case study site, but given the small sample in that case, the project team cautions against making generalizations based on it. Despite the lack of statistically significant results, most of the health and wellness programs were well designed and well implemented. Transit agencies can use the programs examined and the other infor­ mation in this report to help them design wellness programs that can benefit the health of transit workers. The programs provide models and the research on prevalence and costs can suggest where to focus efforts, but consideration should also be given to the specific needs of the workers at any given agency. The project team recommends reviewing the background research on the types of health issues workers are most likely to experience and the programs that are most effective in addressing them. Surveying workers, as was done by several of the agencies studied, is a good way to gauge what kinds of programs will attract worker participation. As noted in Chapter 7, prior TCRP publications include resources to further help design and track programs. The spreadsheet­based tool, “Transit Operator Workplace Health Protec­ tion and Promotion Planning, Evaluation, and ROI Template,” could be helpful. The spread­ sheet is available for download at no charge from the TCRP Report 169 webpage on www.trb.org. Based on the research conducted for this report, the project team suggests using the “Outcome” tab in the spreadsheet as a good starting place for tracking the key measures the programs are meant to impact. The tabs for “Financial Benefits,” “Cost,” and “ROI” provide a way to track results. Using these resources can put agencies on a path to creating programs that benefit workers and will also have a positive impact on the bottom line. 8.3 Study Limitations The research in this report has been subject to several limitations. First, additional cost categories exist that could not be itemized, including quality of service. This limitation primarily resulted from a lack of available data. Moreover, the cost categories can overlap and are not additive as a function of comorbidities. The research approach for this study used cross­sectional data where necessary because it was the only data readily available for a suf­ ficient number of transit workers to answer the fundamental research questions; however, the project team recognizes that cross­sectional data can distort the results. Second, it was not possible to “follow” a transit worker whose career was shortened as a result of job­related injuries or health issues. Similarly, data were not available that would allow the project team to track whether transit workers have shorter lives or more health problems after retirement or leaving transit work for other reasons. It was not possible to account for former transit workers who added to the prevalence rates in the general population. Similarly, the study could not include controls for differences in gender and age in the data analysis on condition costs and prevalence, as this level of detail was beyond the scope of the research. Exploring differential response patterns affected by gender and age would be

106 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line worth examining, recognizing that transit workers are disproportionately older and male in comparison to the general population. Last, this study could not account for differences in local regulations. The number and diversity of local agencies is considerable. Examining how local regulations might affect outcomes could be another fruitful area for future research. The conclusions of the research recognize and have accommodated these limitations and reflect a careful implementation and consideration of the level of detail represented in the original research work plan. 8.4 Areas for Further Research Additional study could be conducted in other cost categories, though some of these cate­ gories may be harder to quantify, including costs to workers in the form of job satisfaction and morale, costs to family in terms of stress and injury, and costs to unions in terms of turnover and management. It would be useful to gather more information on intermediary outcomes related to health, such as changes in hypertension, reductions in type 2 diabetes, and reductions in stress levels. Understanding how programs impact intermediary health impacts and then testing their effects on bottom­line measures such as absenteeism or claims costs would be a fruitful approach to future research. Understanding if wellness programs result in a positive ROI also could help agencies, unions, and workers decide if they are the best use of discretionary funds. Learning more about the actual needs and conditions of workers might further help to better shape health and safety programs. Work that includes surveying transportation workers or conducting in­depth interviews with union leaders could inform the costs experienced in the transit work environment. Work that looks to the future of transit workers and the impacts of higher rates of illness and injury (and the lost days that result) on the industry, as well as work surveying those who exit the industry for health­related reasons, could improve understanding of the effects that health and safety issues can have on the bottom line. Studies that examine these issues using a life­course perspective would be most valuable because they would allow observations of the full health trajectory of transit workers and how they are impacted after retirement or being forced to leave transit work due to injury or disability. Using cross­sectional data to answer these questions is challenging at best and can easily distort the results; however, finding good sources of longitudinal data for this industry will remain a challenge. Providing the context of broader regulatory and geographic frameworks for understanding the health outcomes for transit workers could add further value. A possible question to examine is, “Do state or local regulations have any impact on bottom­line health­related costs for transit workers?” Including regulatory information in either cross­sectional or longitudinal analyses would provide a helpful perspective on the issues. This report will be valuable to research programs in different settings, including industry, labor, and academic venues. It provides a comprehensive summary of the literature and data on chronic conditions among transportation workers that can be used to determine the health and safety issues on which to focus research. An expansion of the data analysis on condition costs and prevalence that controls for differences in gender and age would be a valuable contribution, as would a better understanding of how transportation workers may have a shorter working life than those in other professions. This was something beyond the scope of the present research, but it is worth examining. For industry, a better understanding of the health issues faced by their workers means producing health and wellness programs that could target their issues more effectively—and measuring their efforts by tracking pre­ and post­program outcomes.

Conclusions 107 It is important to understand that the literature shows that very few health and well­ ness programs have impacts, including the cases presented in this report. This suggests that (1) the measures are insufficient, (2) the pre­ and post­observation periods are too short, and/or (3) the interventions are not well­designed. Setting up systems to capture data reliably is challenging and costly. More research on the most effective types of health inter­ ventions clearly is needed, both in general, and specifically for the transportation worker population.