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

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11 2.1 Introduction This chapter presents the key research questions, methodological approach, and specifics of the analytical plan followed for this research. Sections review the research questions this study sought to answer, discuss the overall analysis as informed by an overview of the background research, and detail the quantitative methods for the benefit-cost analysis and the case study design and selection. 2.2 Research Questions The analysis approached the research questions in two main phases. As outlined in the next section, the first phase relied on extant data to answer the research questions. The questions covered in the first phase were as follows: 1. What are the key health issues faced by transit workers? a. What factors contribute to these issues? b. What are the related safety concerns? c. What key metrics are used to measure these issues and their outcomes, as found in the existing literature and current data sources? d. What costs are associated with these issues? 2. What are the current approaches and possible solutions to specific health and safety problems affecting transit employees? a. Where and how are they used? b. What resources are involved? c. What impacts do these approaches and solutions have on health and related safety issues? The second phase incorporated information pulled from public records or provided by agencies, human resources records, insurance company records, and interviews with adminis- trative, human resources, and health promotion program personnel. Additional research ques- tions addressed during the second phase were: 3. What tools and techniques can be used for measuring program costs, benefits, and effectiveness? a. Who benefits and who pays? b. What are the costs, and how are they measured? c. What are the benefits, and how are they measured? d. What is effectiveness, and how is it measured? 4. What potential solutions and tools meet transit agency requirements? a. What barriers will agencies face when implementing the tools and solutions suggested by this study? C H A P T E R 2 Research Design

12 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line b. What steps are proposed to lessen/overcome barriers? c. What tools and techniques are available to support the allocation of funds and imple- mentation of necessary improvements? d. What next steps can build on this research? Research questions 1 and 2 are answered with a review of the literature (Chapter 3), an in-depth analysis of prevalence rates of health conditions for transit workers (Chapter 4), and an exploration of the costs to employers and society of those conditions (Chapter 5). Research Question 3 is addressed via in-depth case studies and an analysis of five health and wellness programs implemented by transit agencies around the United States (Chapter 6). Discussions with these agencies informed the project team’s approach to Research Question 4, particularly as related to identifying and developing suggestions and tools to help agencies overcome barriers to implementing health and wellness programs. Sugges- tions for developing an implementation strategy and for implementing health and well- ness programs are provided in Chapter 7. A standalone implementation document, the TCRP F-26 Implementation Memo, has been made available for download from the TCRP Research Report 217 webpage at www.trb.org. The Implementation Memo provides additional guidance for agencies that wish to use a suggested tool, the spreadsheet-based “Transit Worksite Health Protection and Promotion Planning, Evaluation, and ROI Template,” which is avail- able for download via a link on the TCRP Research Report 169 web page, also at www.trb.org. 2.3 Analysis of National Safety, Health, and Health Cost Data The project team identified health and safety issues, current approaches, and possible solutions to research questions regarding key health issues and their costs. The questions were addressed by examining past research about transit workers’ health and safety, iden- tifying health issues and the factors that contribute to those issues, and discussing how the issues have been addressed. Figure 2 illustrates the process used to carry out this stage of the research. This research identifies the key issues faced by transit workers, the factors contributing to these issues, and the related safety concerns by identifying key metrics, such as measures of the benefits to the employee (e.g., health indicators), the employers (e.g., reduced absen- teeism, costs), and society (e.g., safety and reliability) consistent with the National Institute for Occu pational Safety and Health’s (NIOSH) Total Worker Health™ model. The costs asso- ciated with transit worker health issues also have been identified as they apply to workers, employers, and society. The research team contributed original methods for estimating health-related costs for this population. This approach was necessary due to the dearth of data on health conditions and costs specific to transit workers. The approach taken was to approximate costs associated with transit worker health (i.e., illness and injury) by connecting findings from research on transit workers to findings from population estimates of health-related costs in publicly avail- able data. Data sources included the Centers for Disease Control and Prevention (CDC), Medical Expenditure Panel Survey (MEPS), Social Security Disability Insurance (SSDI), and peer-reviewed research findings. For example, the project team was able to approximate the health costs of transit worker obesity using CDC estimates of obesity-related costs for indi- viduals and aggregating those estimates nationally or by state (CDC 2018a). The identification of targets and conditions under which transit worker initiatives are likely to be most beneficial was considered critical. Thus, whenever possible, the project team also examined differences

Research Design 13 in disease and injury prevalence by such factors as worker sociodemographic variables and environmental factors. The resulting approximations were intended to inform the objective of designing data collection and analytical models for evaluating the impact of transit worker health initiatives. The project team referred to existing peer-reviewed publications on transit workers, data- bases from PubMed, Google Scholar, Repository & Open Science Access Portal’s National Transportation Library, Transport Research International Documentation, and industry orga- nizations to identify common health conditions or work-related health risks for transit workers. Given the prevalence of combining data on transit workers with other transportation areas and the scarcity of more recent data specific to transit workers, a decision was made to include findings from research or datasets that include multiple transportation areas to characterize transit worker health. The project team approximated costs (e.g., financial, employee productivity) associated with common health conditions or work-related health risks in transit workers using peer-reviewed publications and publicly available national datasets. National datasets provide population- level estimates for average economic and productivity costs associated with health conditions and their treatment, and these population estimates were used to approximate economic and productivity costs in transit workers by health conditions and work-related risks. Given that smoking and obesity are known risk factors for cardiovascular disease, diabetes, cancer, respi- ratory disease, and arthritis (CDC 2019a; CDC 2018b), the analysis included medical expen- ditures for disease risk factors and medical conditions in cost approximations. Further, it is understood that as adults age, they are likely to develop more than one chronic condition, which means that medical expenditures are likely to increase at faster rates for older workers relative to younger workers (MEPS 2015). To enable a broader range of cost approximations, the project team included data on healthcare costs, absenteeism, and worker filings for disability benefits. Whenever possible, costs also were broken down by category (e.g., health expenses, lost productivity) and by population characteristics (e.g., age, gender, geographic location) Figure 2. Research design and analytic process for transit worker health condition prevalence and medical expenditures.

14 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line to identify cost-related contexts that may be most impacted and populations who may benefit the most from health promotion initiatives. Finally, developing estimates of economic health costs sometimes involved using sources that themselves combined data from other sources. For example, the Council of State and Territorial Epidemiologists uses data from the U.S. Bureau of Labor Statistics (BLS) and state- based occupational safety and health surveillance data to create measures of the health of the working population, including the transit industry. 2.4 Case Study Identification: Local Health Promotion Programs That Measure Cost-Effectiveness To address the research question about tools and techniques that can be used for measuring program costs, benefits, and effectiveness, the project team conducted a series of case studies that featured a benefit-cost analysis. The case studies, which detail the features of a series of health and safety promotion programs at five transit agencies, include both narratives about the programs and quantitative analyses. Selected sites had either already conducted some form of a benefit-cost analysis or had sufficient data to allow the project team to conduct one. The goal of the benefit-cost analysis was to produce estimates of the impact of programs administered by transit agencies on transit worker health and overall safety. Four of the sites had sufficient data for multivariate regression modeling, though only one produced results with statistical significance. Nevertheless, the qualitative data from all sites provided valuable insights on the types of programs offered and implementation successes and pitfalls. Appendices A and B to this report provide details of the site selection process.