Literature Review of Policy Implications from Findings of the Center for Work, Health and Well-being

Abstract

Objective:

To review the publications of a Total Worker Health® Center of Excellence, the Harvard T.H. Chan School of Public Health Center for Work, Health, and Wellbeing, in order to identify research findings relevant to either organizational or public policies.

Methods:

Two researchers independently reviewed 57 publications from 2011 to 2019 to identify cross-cutting themes that focus on working conditions or related health outcomes and their organizational and public policy implications.

Results:

Twelve cross-cutting themes were identified with their respective organizational and public policy implications. Several policy implications cut across work-related themes.

Conclusions:

Policy implications of TWH® research will aid in setting priorities to translate this from research into practice in future studies and help identify gaps that we and others can use to plan future TWH® research.

Introduction:

The health, safety, and wellbeing of workers and the health and sustainability of the places they work are shaped by policies—both workplace-specific and broadly applicable public policies. Policies may describe or define desirable, expected, or mandatory standards of conduct or behavior. Policy may be regulatory and legally enforceable across workplaces (such as an OSHA or MSHA standard), enforceable in a specific organization or enterprise (workplace rules that, if violated, result in some adverse consequence for the violator), and/or advisory (such as are seen in guidelines from professional associations). A large body of literature underscores the central role that policies play in worker health and safety – ranging from long-standing policies specifically designed to reduce or eliminate exposures to physical hazards on the job, to policies related to work benefits such as healthcare coverage and compensation after an injury on the job.¹

Policies are key in shaping the work environment and consequently workers’ health, yet designing policy based on scientific research can be challenging, as the research itself can be time consuming, expensive, and limited in scope. Collaborations between researchers and policy decision-makers are infrequent, and scientific communications that provide evidence on occupational best practices may not always be accessible or comprehensible to audiences outside of academia.² Furthermore, randomized-control trials (RCTs), frequently considered the “gold standard” for the analysis of policy effectiveness, can be difficult or unethical to conduct in workplaces, as they require long periods of time to assess effectiveness, a counterfactual group may not always be possible or ethical to assemble, and context and individual changes may influence the results even when a control group is available.³ These obstacles exacerbate the disconnect between evidence-informed policy design and decisions made by policy-makers. Nevertheless, we can (and should) consider the policy implications of all research studies, even those that are not RCTs, provided we understand the limitations and generalizability of the work. In many research papers, authors discuss their findings in relation to the broader body of literature, and at times, even the policy implications of the work. This paper seeks to go beyond what may normally be included in a discussion section of many papers, by identifying cross-cutting themes related to policy across the Harvard T.H. Chan School of Public Health Center for Work, Health, and Wellbeing (the Center) body of work. The Center is one of six Total Worker Health® (TWH) Centers of Excellence funded by the National Institute for Occupational Safety and Health. This initiative recognizes the central role of work-related factors in workers’ safety and health, and specifically attends to “policies, programs, and practices that integrate protection from work-related safety and health hazards with promotion of injury and illness prevention efforts to advance worker well-being.”⁴

The Center has conducted a range of studies focused on the different pathways that determine workers’ health, safety and well-being outcomes. These studies gave rise to and have been informed by the Center’s conceptual model, which focuses on how policies, programs and practices impact working conditions and how these conditions determine workers’ health, safety and well-being and mediate workers’ health behaviors.⁵ The research also takes into account these relationships with respect to enterprise outcomes such as turnover rates and absenteeism. The Center’s priorities include understanding the policy implications of its research, in part through the work of its Policy Working Group (PWG). The PWG has conducted an in-depth review of the Center’s body of work, summarized here. The Center’s research investigating the relationships between conditions of work and health outcomes provides a foundation for potential policy applications. Explicating the relationship between “exposures” and “outcomes” can inform the translation of our research findings into policies at the organizational- and public-policy domains.

The purpose of this paper is to conduct a detailed and comprehensive review of the publications of one TWH Center of Excellence, to identify policy implications for this research relevant to both organizational and public policies. We conducted this review in order to identify core policy implications that will inform current policy decisions and identify priorities for future research. Additionally, we also hope that this work can serve as a roadmap for other groups who want to examine their research from a policy implications lens.

Methods

With the aim of providing a comprehensive review of the Center publications, we included all peer-reviewed articles based on Center work funded by NIOSH TWH^®. These articles were published between 2011 (when the first Center-funded research was published) and mid-2019 when the review was submitted for publication. To be included in the review, a publication must involve analysis of an association between aspects of the work environment and health outcomes, meaning case studies, creation and/or validation of measurement tools, or literature summaries were excluded from this analysis.

To initiate the review, two policy working group members (MALG and ESF) independently reviewed each publication, following a standardized protocol for data extraction and review. The two reviewers independently extracted details about each manuscript using a standard form, to record the following information: policy implications, study methods and results, whether or not policy implications were explicitly or implicitly discussed, at which level the policy was focused (e.g. organizational or public), generalizability, key limitations, and scientific gaps. For a full list of extracted details, see Appendix A . Findings from these reviews were examined by each publication’s authors for additional input on policy implications.

The reviewers then conducted an iterative, detailed, and rigorous review of the extracted policy implications and grouped them by cross-cutting themes. In the case of varying assessment of policy implications between reviewers and the author, all identified implications were included in the results presented here. The cross-cutting themes fit under two umbrella topics, that reflect the majority of the center’s research: working conditions (e.g. job demands and decision latitude, and social support) or related health outcomes (e.g. physical activity and psychological distress). However, it should be noted that the themes often cut across these two categories, as often one working condition is associated with several health outcomes and one health outcome is associated with several working conditions.

Results

This review included 32 out of the 57 publications that covered the Center’s work and affiliated projects from 2011 to 2019 (Table 1). Twenty-five publications were excluded from this analysis because they did not meet inclusion criteria. All authors generally concurred with the reviewers’ initial assessment or added comments that further expanded the reviewer conclusions. The final framing of policy implications is a combination of the conclusions of the two reviewers and primary author of each publication.

Table 1:

Industry Type and Study Design of Reviewed Studies

	Number of papers N (%)
Industry
Healthcare	29 (91)
Construction	3 (9)
Study design
Cross-sectional	13 (41)
Cross-sectional with a longitudinal component	13 (41)
Case-control	2 (6)
Clustered randomized controlled trial	1 (3)
Longitudinal administrative data only	1 (3)
Intervention	2 (6)

Review findings

As summarized in Table 2, we identified twelve cross-cutting themes among the reviewed publications, focusing on either working conditions or related health outcomes that in turn have policy implications at the organizational and/or public policy levels.

Table 2:

Examples of Policy Implications from findings of the Center for Work, Health and Well-being

Center Papers Focus on these topics		Implications based on the Center’s Work
Working conditions	Research Findings	Organizational Policy	Public Policy
Ergonomic Practices	Decreased ergonomic practices were associated with reported increased levels musculoskeletal pain in four body areas (low back, neck/shoulder, arms, and lower extremity) in the past 3-months.7 Decreased ergonomic practices were also associated with symptom severity and limitations in completing activities of daily living in the past week.7 Implementation of a construction ergonomics program was associated with an increase in ergonomic practices, and a reduction of musculoskeletal pain and injury reports.10 Increased ergonomic practices was associated with increased preventative care utilization8 and decreased work limitations9	Policies to improve ergonomic practices	Policies to improve ergonomic practices
Harassment and abuse	Higher levels of workplace harassment were associated with obesity11, injuries (especially musculoskeletal injuries)12, 13, and sleep deficiency12 Workers who reported incivility or bullying had increased odds of mental health related claims14	Policies to prevent abuse, harassment, discrimination, and violence (this also applies to patients and family members, in the example of healthcare) Policies to build respect for the ideas, values, and beliefs of others Building shared responsibility of violent acts through restorative circle processes where workers who were actively and passively involved in bullying discuss constructive strategies to change the situation and prevent future occurrences	Zero-tolerance policy towards workplace harassment and abuse by agencies at the local, state, and federal levels
Safety practices	Positive safety practices were associated with decreased self-reported sharps injuries (but not administrative records of these injuries)17 and positive measures of job satisfaction.16 A safe patient handling and mobilization program that uses an integrated systems approach was associated with improved work practices and a reduction in recordable worker injuries.18	Policies that support positive safety practices (and improve communication surrounding safety practices)	Policies to support positive safety practices
Social Support (supervisor and/or co-worker)	Increased supervisor support was associated with lower injury rates19,20 and superviso’s support for meal breaks also increased amount of meal breaks21 taken by workers which in turn was associated with lower psychological distress. Low social support was associated with increases in musculoskeletal pain22, low back pain7 and sleep deficiency.12	Policies that hold supervisors accountable for taking actions that support their employees (e.g. encouraging breaks) Policies and trainings to be implemented that aim to prevent abuse, harassment discrimination and violence, and that encourage employees and supervisors to build respect for the ideas, values and beliefs of others	Regulations and/or standards for psychosocial factors
Staffing level	Perceived inadequate staffing may be associated with higher prevalence of back pain.26	Regular assessment of staffing adequacy Policies (that include staffing levels) to evaluate and address the extent to which job demands are aligned with resources	Staffing ratio regulations
Work-family conflict	Increased levels of work family conflict was associated with increased sleep deficiency30 and musculoskeletal pain31	Scheduling policies to reduce work-family conflict Discourage stigmatization and/or sanctioning of workers for enabling their right to schedule control	Scheduling regulations
Work schedules	Increased job flexibility was associated with increased physical activity11, lower levels psychological distress,32 increased preventative care utilization8, and job satisfaction33 Shift characteristics were associated with lower injury rates.34 Meal breaks were associated with lower levels of psychological distress.21	Scheduling policies (e.g. related to flexibility) Break policy consistently enforced	Scheduling regulations
Work stress/Job Demands/Decision making	Increased psychosocial demands and low decision latitude were associated with increased musculoskeletal pain7,29 and reduced physical activity11,35	Regular review of job responsibilities to ensure appropriate work load Changes in job demands and shift scheduling	Scheduling regulations and/or standards Healthcare example: Regulations requiring measurement of nurse-to-patient ratio to assess job demands
Health Outcomes	Research Findings	Organizational Policy	Public Policy
Injuries and injury reporting	Positive safety practices were associated with self-reported sharps injuries but not administrative records of these injuries.17 The undercount of occupational injuries in administrative versus self-report data may be greater among black compared to white workers, leading to underestimates of racial disparities in workplace injury.36 Injury rates within the same hospitals differ by occupation and type of unit.39 Work-related injuries were associated with increased odds in having medical expenditures at both 3 and 6 months after injury37 The effect of an intervention aimed at reducing injuries among a diverse group of workers may have differential effects, which could widen disparities38	Procedures that allow for easy reporting of injuries and that also prohibit retaliation of injury reports Data-driven surveillance systems that can capture distribution and disparities of injuries within the workplace to be able to design and implement appropriate interventions Implementation of policies in diverse populations should be responsive to disparities present in the targeted population	Reporting regulations and/or standards Create surveillance systems for occupational injuries that segregate by occupation, type of work and context
Mental health	Mental distress was associated with increased self-reporting of injury40, musculoskeletal pain40, and pain interference with work.41 Workers who reported incivility or bullying had increased odds of mental health related claims14	Policies that contribute to a psychologically safe and healthy environment. Implement an internal monitoring system that is able to capture psychological hazards at the workplace on a continuous basis. Policies that allow for easy access to mental health resources	Policies that protect workers against psychological hazards created by economic changes (e.g. unemployment benefits, regulations on types of contracts) Policies that make the employers accountable in the protection of workers against psychological hazards at the workplace
Physical activity	Construction workers obtain a substantial amount of physical activity at work.44 Vigorous occupational physical activity was significantly and positively associated with self-reported fatigue.44 Self-reported fatigue and functional limitations were negatively correlated with measured minutes of vigorous activity outside of work.45 Workers who did not meet physical activity guidelines reported low decision latitude7 and an increased 10-year cardiometabolic risk.46	Policies to evaluate and address the extent to which job demands are aligned with resources Implement integrated worksite interventions that target improvements in physical activity (as well as other outcomes) through shared pathways of working conditions	Policies that support healthy lifestyles habits such as tobacco cessation, healthy diets, reduction of alcohol abuse, and improvements in sleep hygiene
Sleep deficiency	Sleep deficiency was associated with overweight and obesity11, as well as increased musculoskeletal pain, work interference, and functional limitation47, harassment at work12 and increased 10-year cardio-metabolic risk.46	Scheduling policies designed to protect sleep cycles	Scheduling regulations

Working Conditions

Ergonomic practices

Several Center studies involved examining the relationship between ergonomic practices and various health outcomes. Ergonomic practices were measured using a modified version of the Organizational Policies and Practices questionnaire developed by Amick, et al., 2010.⁶ Questions focused on workers’ perceptions of the design of the physical work environment and the promotion of the use of tools for reducing biomechanical workload. Results from Center studies found that decreased ergonomic practices were associated with increased levels of self-reported musculoskeletal pain in four body areas (low back, neck/shoulder, arms, and lower extremity) in the past 3-months.⁷ Additionally, increased ergonomic practices were found to be associated with increased preventive care utilization⁸ and decreased work limitations (a measure of the degree to which someone experiences limitations at work due to health problems and health-related productivity loss).⁹

The findings from the Center’s studies on ergonomic practices demonstrate the importance of strong ergonomic practices at the workplace.¹⁰ Implementation of clear policies that support positive ergonomic practices, at the organizational and/or public policy level, could help to improve working conditions and in turn, impact a range of outcomes, including non-occupational outcomes such as preventive care utilization. These findings also strengthen the case for engaging employees in improving ergonomic practices .⁷ Although there are no federal regulations that explicitly focus on ergonomics, data from the Center demonstrate the importance of ergonomic practices and policies at multiple levels.

Harassment and abuse

Workplace harassment was associated with obesity¹¹, injuries^12,13, and sleep deficiency.¹² Workers who reported incivility or bullying also reported higher rates of mental health claims.¹⁴ In their discussions, authors integrated policy-relevant evidence of potential factors that may reduce or eliminate harassment and verbal abuse at work for patient-care workers. These conclusions were summarized by Sabbath 2014 et al.: “Intervention efforts could be deployed at the organizational, interpersonal and individual levels in order to reduce prevalence of abuse and its associated risk of injury.”¹³ Policy implications emphasized an integrated organizational approach towards creating a culture and climate that protects against abuse, but also supports workers at different levels.^11-13 This emphasizes the responsibility of leaders and managers to promote awareness about physical and verbal abuse. Furthermore, as described by Sabbath et al. 2014, “administrative efforts to reduce workplace verbal abuse may be most effective if they simultaneously address the overall social context of the unit and specific interactions between a worker and a workplace abuse perpetrator.”¹³ This statement highlights the fact that while workplace policies may be effective in reducing harassment and abuse, it is critical to account for the intricacies of specific workplace environments.

OSHA has also developed some examples of workplace violence prevention guidelines that include: the establishment of clear policy addressing workplace violence, verbal and nonverbal threats, and related actions; encouraging workers to report any incidents and suggest ways to prevent them, assigning responsibility and authority for the violence prevention program to individuals or teams with appropriate training and skills, and affirming management commitment towards worker health and safety.¹⁵ From a legislative perspective, efforts to establish a zero-tolerance policy towards workplace abuse (that includes abuse from co-workers and supervisors, and in the healthcare setting, patients and families) may help towards improving the working conditions for workers and in turn, have a positive impact on health outcomes.

In addition, Nelson et al. 2014 cited a strategy to prevent harassment from the nursing literature that encourages workplaces to build social supports among patient care workers, thereby sharing the responsibility for negative behavior and/or violent acts among all workers.¹¹ This is consistent with specific actions mentioned by Sabbath et al. 2014: promotion of an informative discussion about harassment and abuse in workers’ trainings, creation of “procedures for reporting and investigating incidents in a swift and anonymous manner” and eliminating or making appropriate changes to situations that may precipitate violence such as receiving bad news, long waiting times and limited visits.¹³ At the interpersonal level, Sabbath et al. 2014 made recommendations that organizations could provide guidelines for interactions among workers but also between patients and their families with health care providers. These guidelines could focus on workplace social norms against abuse, as well as other organizational factors such as trust and cooperation.¹³

Safety practices

Center studies focusing on safety practices were measured by using a modified version of the Organizational Policies and Practices questionnaire by Amick, et al. 2010.⁶ The safety practice subscale focused on questions around workers’ perception of safety leadership, safety training, and safety diligence. Results showed that positive safety practices, characterized by the identification and control of occupational hazards, are associated with higher job satisfaction¹⁵ and a decrease of self-reported sharps injuries¹⁷ (but not administrative records of these injuries). An intervention study in a hospital setting observed positive perceived safety practices and a reduction in recordable worker injuries when the focus of the intervention was on integrated efforts at a system level to improve safe patient handling by patient-care workers. The intervention focused on earlier and more frequent mobilization of patients using lifts and slings. Without proper and systematic use of this equipment, lifting patients has the potential to increase workers’ physical demands.¹⁸ Furthermore, program was successful due in large part to the system-wide policy implemented in the context of an improvement in patient safety. The multi-component program included training, clear communication of the policy, coordination across departments, and engaging leadership in support of the program.

Organizational policies that identify and manage safety hazards through a systems level approach that includes engagement of leadership, coordination across multiple departments and fostering system-wide communications can align the goals of worker safety with patient safety¹⁸ and job satisfaction.¹⁹

Social support

Two studies conducted with a sample of patient-care workers found that social support was associated with lower injury rates.^19,20 Tveito et al. 2014 found that co-workers’ support was associated with lower injury rates in bivariate analyses; this association was found among registered nurses, but not among patient-care associates, and was not found for the relationship between supervisor support and injury rates.¹⁹ However, a study by Reme et al. 2014, which controlled for additional working conditions and job title, found that supervisor support, but not co-workers support, was associated with lower injury rates and that rates were significantly lower for workers with musculoskeletal injuries than for workers with other types of injuries.²⁰ In both studies, the authors underscored the importance of looking at musculoskeletal injury from a multi-causal perspective that would suggest the need for organizational policies that support several factors, one of them being social support.

In other studies, supervisor support was found to be associated with increased frequency of meal breaks, which in turn related to lower psychological distress.²¹ Low social support has also been associated with musculoskeletal pain²² and sleep deficiency.¹²

Policy implications related to social support include the importance of holding supervisors accountable for taking actions that support their employees. This accountability could be promoted by offering trainings to build skills and providing supervisors resources for supporting employees. Policies and trainings aimed at preventing abuse, harassment, discrimination and violence, as described above, and that encourage employees and supervisors to build respect of the ideas, values and beliefs of others also support a thriving environment for social support.

Results from the Center’s work support the importance of creating psychosocial standards at the public policy level. Currently, OSHA in the US does not explicitly include regulations on psychosocial factors or mental stress at work²³, but does provide some voluntary guidance. Nonetheless, examples of such standards exist elsewhere. For example, the European Agency for Safety and Health at Work (EU-OSHA) has published guidelines on identifying, preventing and managing psychosocial risks, as well as setting a legal imperative with the Framework Directive 89/391/ECC that sets minimum standards on technical safety but also on prevention of ill-health.²⁴ Canada also has a voluntary standard, “Psychological Health and Safety in the Workplace,” that aims to promote worker psychological health and prevent psychological harm resulting from workplace factors.²⁵

Staffing Levels

Kim et al. 2014 found that perceived inadequate staffing from patient-care workers in a hospital setting is associated with musculoskeletal pain even after controlling for demographic variables and physical work factors that measure time spent doing different types of physical effort during a shift.²⁶ Results suggest that at the organizational level two activities could reduce musculoskeletal injury as follows: i) assessing regularly whether staffing level is sufficient among hospital workers, and ii) providing adequate staffing. The authors suggested that assessing perceived inadequate staffing from workers themselves might be a better approach to align job demands with available resources than merely considering administrative data on number of patients per nurse.

An example of a proposed federal regulation intended to address this issue is HR5052/S2446 - Safe Staffing for Nurse and Patient Safety Act of 2018, which was introduced in Congress in February of 2018 and is currently under committee review. Another example was the 2018 ballot initiative in Massachusetts (the Initiative Petition For A Law Relative To Patient Safety And Hospital Transparency). While it did not pass, the proposed initiative would have required that hospitals have mandated nurse-staffing levels. Although the Center’s papers do not explicitly evaluate specific staffing ratios, they support scheduling shifts and tasks to optimize the work experiences of nurses, which might be accomplished through regulation of staffing ratios.

Work-family conflict

Work-family conflict arises when time, participation and behaviors required for one role (work role) make it difficult to fulfill requirements for another role (non-work role). ²⁷ In the past century, the composition of the workforce has changed significantly with increased participation of women, single-parent households and an ageing population, but little has been done on policies on work organization and social benefits supportive of achieving work-life balance that allows workers to fulfill other non-work roles such as caregiving for children and older adults.^27,28 Evidence from studies conducted with the Boston Hospital Worker Health Study (BHWHS) shows that higher levels of work-family conflict are associated with sleep deficiency²⁹ and with musculoskeletal pain³¹ in several parts of the body, even after controlling for relevant factors such as job stress and psychological distress.³⁰

Work-family conflict and related ill outcomes may be attenuated and prevented by designing policies and interventions that prioritize job flexibility and discourage stigmatization and/or sanctioning of workers for enabling their right to schedule control, urging employees to prioritize sleep and attain work-family time balance. The aim of this organizational policy would be to nurture long-term wellbeing and effectiveness of employees. In the public policy arena, policies that establish minimum and maximum shift hours and a minimum amount of hours between shifts may be able to influence work-life balance in a positive way.

Work Schedules

Our review included multiple papers that generated research findings related to work schedules. For example, four papers examined job flexibility among patient care workers, finding associations between job flexibility and increased physical activity¹¹ as well as lower levels of psychological distress³² increased preventive care utilization⁸, and increased job satisfaction.³³ Another paper found that shift characteristics (e.g., longer shifts, more consecutive days worked, longer total hours worked, more night shifts, and more frequent overtime) were associated with higher injury rates.³⁴ A fourth paper found a positive association between the frequency of meal breaks and lower levels of psychological distress.²¹

These research findings support organizational policies intended to improve work schedules, such as scheduling policies that encourage flexibility in task scheduling and working hours, and a break policy that is consistently enforced. For example, Hopcia, et al., 2012 found that consecutive shifts of two or more days, as well as cumulative shifts over a week and month (especially night shifts) were associated with increased odds of an injury.³⁴ Hopcia noted in the paper: “Occupational health nurses should assess, when possible, whether policies address details such as minimum number of days or weeks on a specific shift, how shifts rotate, number of days that can be worked consecutively without a day off, the maximum length of a shift, or the amount of overtime in a given shift or week.”³⁴ This is a reminder that an important organizational policy involves regularly reviewing shift characteristics. Similarly, another related policy example relates to breaks within a work day as important organizational policy, as Hurtado et al. 2015 notes: “Meal breaks should provide daily opportunities for fatigue recovery; for access to healthier, more enjoyable meals; to enjoy meals and leisure or personal time, factors that explain the positive effect of meal breaks on mental health.”²¹

Work Stress, job demands and decision-making

Evidence from the Center’s studies showed that psychological demands and decision latitude have implications for physical health outcomes and workers’ health behaviors. The combination of high psychological demands and low decision latitude were associated with increased musculoskeletal pain among patient-care workers.^12,22 On the other hand, greater decision latitude and job flexibility was associated with greater physical activity.¹¹ A study by Arias et al. 2017 with patient-care workers found that workers reporting moderate and vigorous levels of physical activity at work actually spent 99% of their work time below moderate and vigorous activity as measured by an accelerometer. ³⁵ Authors suggested that this perceived differential may be due to the fatigue created by high job demands related to trunk flexion and bends, also measured with tri-axial accelerometer, but not by actual physical activity (same reference).

Evidence from these studies demonstrates the importance of modifying organizational policies to support adequate job demands and increased job flexibility. Organizations may be able to modify job demands by regular reviews of job responsibilities to ensure that workers have manageable workloads. Public policies that could support adequate job demands include the creation of scheduling regulations and well-designed patient-to-nurse ratios.

Health Outcomes

Injuries and injury reporting

The Center also conducted research that focused on factors that were related to injury reporting, along with the distribution of injuries in the workplace. For example safety practices were found to be associated with self-reported sharps injuries but not administrative records of these injuries.¹⁷ Additionally, Center work found that the undercount of occupational injuries in an administrative dataset was greater among black workers when compared to white workers.³⁶ Another Center paper found that workers with an injury reported increased medical expenditures at both 3 and 6 months post-injury.³⁷

Organizational and public policy implications that relate to such findings include policies that seek to reduce barriers to injury reporting or reward reporting of adverse events and near misses, or policies that seek to prohibit and punish retaliation following an injury report.

In a recent paper by Sabbath et al. 2019, authors re-analyzed the results of a Center intervention evaluation¹⁸ and found that while the intervention had a positive impact overall, this effect did not benefit all populations equally and may in fact have contributed to widening disparities.³⁸ Thus, these results underscore the importance of tailoring interventions, as well as policies, to the group of workers who are most at risk and often have the least amount of agency. These results also reiterate the need to account for diverse populations in a workplace.

Center research on occupational injury also examined the distribution of injuries within the workplace. For example, one study found that injury rates within the same hospital differed by occupation and type of unit.³⁹ The policy implications of this work suggest that data-driven surveillance systems put in place at the organizational and/or public policy levels may be able to capture the distribution of injuries within an organization, and thus can be used to help target preventive workplace interventions. Additionally, the research suggests that policies should seek to provide consistent definitions of injury and exposure terms.

Mental health

Research from the Center indicated that mental distress was associated with increased self-reported injury and musculoskeletal pain⁴⁰ as well as with increased pain interference with work.⁴¹ Additionally, increased levels of mental health related claims were associated with workers who reported incivility or bullying.¹²

These findings support policies at both the organizational and public policy level. For example, the finding that psychological distress is closely associated with injury and pain outcomes provides evidence of the importance of creating policies that contribute to a psychologically safe and healthy environment. The authors point to the need for more research on the topic, noting that: “an intervention targeting psychological factors that has the potential to prevent disability, reduce injuries, alleviate mental distress, and reduce health-care costs in more than 11 million [construction] workers, certainly warrants a rigorously designed large-scale study.”⁴⁰

Improvements to psychological environments may include implementing an internal monitoring program that records psychological hazards in addition to physical hazards and facilitates regular updates to this system.

The Center’s findings also provide supporting evidence for many public polices, such as those that hold employers accountable in the protection of workers against psychological hazards. Some countries are beginning to include psychological hazards under the umbrella of their occupational safety and health administrations (e.g. Australia and Canada).²⁵ Other public policies, such as unemployment benefits, regulations on types of work contracts, or even minimum wage policies may prevent exposure to psychological hazards created by economic challenges.^{42, 43}

Physical activity

Several studies from the Center focused on physical activity, specifically aiming to investigate the relationship between work-factors and occupational and/or recreational physical activity. For example, research in the construction industry indicated that construction workers have a substantial amount of physical activity at work, and that this was positively associated with self-reported fatigue.⁴⁴ A related finding from a study in the health care industry found that self-reported fatigue and functional limitations were negatively correlated with measured minutes of vigorous activity outside of work.⁴⁵ Another paper found that workers who did not meet physical activity guidelines reported lower levels of decision latitude and an increased 10-year cardiometabolic risk.⁴⁶ The Center’s findings imply that policies designed to evaluate and address job demands may provide more time for workers’ physical activity outside of work, which in turn may have a number of health benefits.

Sleep deficiency

Studies found associations between increased sleep deficiency and higher rates of overweight and obesity among health care workers¹¹, as well as between increased sleep deficiency and increased musculoskeletal pain, work interference, and functional limitations.¹¹ Another study found that health care workers who reported higher levels of sleep deficiency had an increased 10-year cardio-metabolic risk.⁴⁶

The findings from these studies imply that policies, at the organizational or public policy level, that are designed to protect sleep cycles are recommended. For example Buxton et al. 2012 notes that multi-level interventions for workers that acknowledge how individuals fit into the overall work context may be effective at reducing sleep deficiency.⁴⁷ Buxton notes that: “policies that provide increased flexibility on shift length and timing may contribute to a supportive work environment that acknowledges the pivotal role of sleep in worker health outcomes. In tandem, educational programs to inform workers of the important associations between sleep, musculoskeletal disorders and pain may motivate workers to consider improved sleep hygiene practices.”⁴⁷

Discussion

Our goal was to provide a thorough review the publications of our TWH® Center of Excellence, the Harvard T.H. Chan School of Public Health Center for Work, Health, and Wellbeing to identify policy implications of this research that would be relevant to both organizational and public policies. Our review extended beyond the policy implications of individual articles in order to extract cross-cutting themes. The definition of TWH® and the approaches involved in developing and implementing TWH® programs are still relatively new, only taking shape in the last few years. We hope that this review can help lead the way for additional consideration of the policy implications of TWH research and serve as a model for other groups considering the policy implications of their own work, thus facilitating the translation of TWH® research to practice.

The review involved extracting research findings from the Center’s body of work, organizing them into twelve policy-related themes that fell into two categories: working conditions (e.g. social support, safety practices) and related health outcomes (e.g. mental health, physical activity). These categories and the themes align with the Center’s conceptual framework.⁵

Results show that policy implications related to the TWH® framework cut across work-related themes. This underscores that working conditions interact with one another; that is, characteristics of one working condition may generate changes in other working conditions that at the same time may have an impact on workers’ health and behavior. For example, the policy implications of research findings from the themes of work schedules, sleep deficiency, and work-family conflict all support scheduling policies at the organizational level and scheduling regulations at the public policy level. Similarly, the research for both social support and harassment/abuse implies that organizational policies should aim to prevent abuse, harassment, discrimination, and violence. These multiple shared pathways reflect one of the core components of TWH® -- that shared pathways of certain working conditions can affect multiple health outcomes.

This review has several benefits. First, it allows us to understand the potential impact of our research and helps set priorities for translating this work from research to practice. Second, we were able to demonstrate the feasibility and utility of conducting a review that draws out relevant policy implications of TWH® research and can serve as an exemplar for other groups seeking to understand their own body of work. Third, this review allows us to identify gaps in our own work that we and others can use to plan future research priorities.

It is worth mentioning that from the 57 articles reviewed, 25 of them did not study associations between the work environment and health outcomes, and thus did not include implications related to organizational and public policy. These 25 articles included pilot studies, case studies, creation and/or validation of measurement tools, commentaries summarizing the literature and/or providing relevant information for future research and the Center’s conceptual framework which summarizes a research agenda that addresses disease prevention by integrating health protection and health promotion in the workplace. Our approach in this study involved extracting policy implications based on results from the study of working conditions and health outcomes, thus, the above-mentioned articles were not included in the results of this review. Nevertheless, they could potentially contribute to the design and study of policies that impact the workplace. Validated tools may aid in measuring the effectiveness of organizational policies and practices and conceptual frameworks can help guide the design and analysis of policies.

Although policy implication reviews have been conducted in other aspects of occupational health^48-50, to our knowledge, this is the first time such review has taken place within TWH® research framework, but limitations should be addressed. First, our review highlighted a few scientific gaps that should be addressed in future research. For the most part, the Center’s body of work only includes a limited number of working populations, and thus the policy implications described may only be generalized to these populations. The study populations were relatively homogeneous, consisting mostly of women in the health care sector and men in the construction industry, as well as a predominantly white population, although some work covered small to medium sized businesses and two studies focused on racial disparities and injury reporting.^17,36 Most of the studies were also cross-sectional and/or involved retrospective and self-reported data where exposure and/or outcome misclassification may be a concern.

This review of policy implications is not the study of policy effectiveness; for this, we would need to include review of the broader scientific literature. Literature published by authors outside of the Center was beyond the scope of this analysis. While the entire body of scientific literature on a given topic should be consulted when developing policies for organizations or the public, here we aimed to only focus on the implications of the research generated by the Center.

Despite these limitations, the strengths of this process are noteworthy. While a challenging and iterative process that required the knowledge and collaboration of authors and reviewers, this innovative method aimed to set a policy lens on TWH® research. We conducted a detailed and comprehensive review by two independent reviewers that was checked by study authors, all of which increases the robustness of this study. We believe that the results described here will aid in setting research priorities that will in turn translate findings to inform policy.

Conclusions

In this paper, we considered the policy implications emerging from a comprehensive review of one TWH® Center’s scientific output and the value of the review in identifying policy gaps to assist in setting future research priorities. Ultimately, policies can either advance or impede the potential of TWH® to make a difference in the lives of workers and the success of employers. We identified cross-cutting themes from our research findings and the associated policy implications at both the organizational and public policy levels.

This review process can serve as a model for other research groups who seek to examine the TWH® policy implications of their own work and identify future areas of focus. By reviewing our research to date, we have identified common themes and related policy recommendations, along with some important scientific gaps for future research. We were able to demonstrate the feasibility and utility of conducting a review that draws out relevant policy implications of TWH® research. We hope that this review can serve as a model for other groups and can lead to an increased focus on policy discussions in manuscripts.