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National Institute for Occupational Safety and Health

Expanded Focus for Occupational Safety and Health: A paradigm shift

Sarah A. Felknor, DrPH and Paul Schulte, PhD

University of Utah

17th Annual NORA New Investigator’s Symposium

April 18, 2019

Acknowledgements

Rene Pana‐Cryan, PhD

Teresa Schnorr, PHD

Anita Schill, PhD

Rebecca Guerin, PhD

Gregory Wagner, MD

Many NIOSH thought leaders

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The world of work is undergoing profound changes.

Changes in the nature of work

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Traditional vs. non‐standard work arrangements

Traditional one employer over a lifetime career thing of the past 

Increase in alternative or non‐standard work arrangements 

– Contingent, temporary, part‐time, contract, and ‘gig’ arrangements

– Lack of permanence and loss of legal protections for a safe workplace

– Considered flexible work for employers and precarious work for workers

30% of all establishments use alternative work arrangements

Contingent workers represent 30% of the workforce 

– Highest among Hispanic or Latino ethnicity

– Lower paid than same educational level among permanent employed

– Few or no benefits

[Capelli and Keller 2013; BLS 2017; Howard 2017, Cummings and Kreiss 2008]

Risk of non‐standard work arrangements

Evidence that work arrangement may put workers health at risk

– “Irregular, unstable, temporary or precarious working conditions common to what is usually known as informal work in developing countries” [Siqueira 2016]

Non‐standard arrangement shifts risk of doing business to worker 

Manner by which work arrangements may increase risk is not known

[Siqueira 2016, Howard 2017] 

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Work organization and intensification

New ways of organizing

– Contracting

– Downsizing

– Lean manufacturing

Work intensification

– Designed to increase productivity

– Technology driven

– More work and less recovery time

– Correlates with psychological distress

Changes in the nature of work bring new and unknown workplace exposures and risks that may affect workers’ health 

disproportionately.

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Changes in the workforce

Changes in the workforce

Multigenerational

More turnover

Less unionization

More chronic disease

Older workers

More immigrants

More women

More veterans

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Total economic impact of chronic disease $1.3 Trillion, 2003

$48

$33

$46

$65

$45

$27

$14

$271

$280

$171

$105

$94

$105

$22

$0 $50 $100 $150 $200 $250 $300 $350

Cancers

Hyperternsion

Mental Disorders

Heart Disease

Pulmonary…

Diabetes

Stroke

US$ Billions

Total Treatment Expenditures = $277B Total Lost Economic Output = $1,047B

[DeVol & Bedroussian 2007]

Lost productivity due to chronic disease $ 1046.7 Billion, 2003

79%

8%

12% 1%

US$ Billions

Presenteeism Individual - $828.2

Presenteeism Caregiver - $80.2

Lost Workdays Individual - $127.5

Lost Workdays Caregiver - $10.8

[DeVol and Bedroussian 2007]

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Forgone economic output due to chronic disease, 2005 – 2050

DeVol & Bedroussian 2007

Changes in the workforce challenge traditional health and safety systems to ensure a safe and healthy workforce.

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Changes in the workplace

Changes in the types of workplaces

More small businesses

– Majority of businesses across all sectors in U.S.

– Employ disproportionate number of workers in high risk sectors

More telecommuting

New work conditions

New work plans

New work contracts

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The workplace is a mosaic of hazards

Changes in work, the workforce, and the workplace bring new hazards and risks

While we still face older deadly hazards and risks

Transition

Traditional OSH approach recognizing hazards and eliminating associated risks 

Comprehensive view of the burden of work and 

work‐related adverse effects

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Traditional OSH paradigm

Traditional OSH paradigm involves the identification and elimination of risks associated with work

Occupational health surveillance systems are largely injury focused and don’t adequately capture occupational disease

Historically narrow view of OSH injury and illness with emphasis on injury

Results in underestimated and under‐recognized burden of workplace injury, illness, and disability

Comprehensive view of work‐related burden

Multiple domains of burden

– Individual worker – workers’ family – community – employer – society

Broader view of work‐relatedness of disease and injury

– Occupational injury and illness

– Work‐Related injury and illness

Impact over the entire working life continuum

– Considers occupational and work‐related burden over a lifetime including periods of unemployment

Concept of well‐being as a more comprehensive indicator

– Challenge of lack of consensus of how to define and apply

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A paradigm shift is needed to an expanded focus for occupational safety and health.

Broader view of burden vertically and horizontally 

Personal Risk Factors

Social & Economic Risk Factors

OSHOSH

WorkingLife

Continuum

Personal Risk Factors

OSHSocial & Economic Risk Factors

Current Broader horizontally

Broader horizontally and vertically

Expanded Focus Broader Horizontally

Well-being

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[Schulte et al 2017]

Multiple domains of burden

Broader view of the role and impact of work 

Many of the most prevalent and significant health conditions in workers not caused solely by workplace hazards

⁻ Examples include stress‐related conditions, cardiovascular, psychological, and musculoskeletal disorders, obesity, depression, substance abuse, and violence

Separation of “work” and “non‐work” is in some ways artificial

⁻ Due to labor or employment contract

⁻ Compartmentalization leads to under‐reporting

⁻ Increasingly porous boundaries between work and home

Need for broader consideration of interaction of work and non‐work factors

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Morbidity, mortality, and injury 

Primarily caused by chemical, physical, biological, and psychosocial factors in the workplace

Single identifiable and measurable exposure in the workplace

Example: mesothelioma and coal miners’ pneumoconiosis

Directly attributable to a workplace exposure to asbestos and coal dust

Diseases in the working population in which the work environment and the performance of work contribute significantly but as one of a number of factors to the causation of disease.

Causation of new or aggravation of existing disease of non‐occupational origin

Example: musculoskeletal disorders

Occupational Disease and Injury Work‐Related Disease and Injury

Personal Risk Factors

Social & Economic Risk Factors

OSHOSH

WorkingLife

Continuum

Personal Risk Factors

OSHSocial & Economic Risk Factors

Current Broader horizontally

Broader horizontally and vertically

Expanded Focus Broader Vertically

Well-being

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Personal Risk Factors

Social & Economic Risk Factors

OSHOSH

WorkingLife

Continuum

Personal Risk Factors

OSHSocial & Economic Risk Factors

Current Broader horizontally

Broader horizontally and vertically

Expanded Focus Broader Vertically

Well-being

JOB N

Occupationalhazards

and risksn

Work-related hazards

and risksn

NON-WORK HAZARDS AND RISKS

Working Life

Pre-work

(school/training)

Post-work

(retirement)

• Unemployed• Between jobs• Precarious employment

JOB 1

Occupationalhazards

and risks1

Work-related hazards

and risks1

The working life continuum and dynamic nature of work

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Number of jobs in a lifetime

Born between 1957 – 1965

Ages 18 – 48 11.7 jobs (average)

Men 11.8 jobs

Women 11.5 jobs

27% cohort 15 jobs or more

10% cohort 0-4 jobs

BLS 2015

Repeated spells of unemployment

Born between 1957 - 1965

Ages 18 – 48 5.6 (average)

high school dropout 7.4

high school graduate5.6

college graduate3.9

33% high school dropouts22% high school graduates

6% college graduates10 or more

[BLS 2015]

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Unemployment and health

Physical and mental health effects

Job loss increases odds of fair or poor health by 54%

Job loss increases odds of new health conditions by 83% among those with no pre‐existing conditions

[Strully 2015]

Underemployment and health

Underemployed workers report lower levels of health and well‐being

Underemployed: Not having enough adequately paid work or not doing work that makes full use of a worker’s skills or abilities

Types associated with lower levels of health

– Hours based

– Income based

– Skill based

– Status based

Underemployment seems to have health effects more like those of unemployment than adequate employment

[Friedman and Price 2003]

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JOB 1

JOB 2

JOB N

Cumulative health effects?

Healtheffects

Health effects

Health effects

Health effects

Employment

Underemployment

Employment

Underemployment

Employment

Underemployment

Health burden within and between jobs

unemployment

unemployment

Personal Risk Factors

Social & Economic Risk Factors

OSHOSH

WorkingLife

Continuum

Personal Risk Factors

OSHSocial & Economic Risk Factors

Current Broader horizontally

Broader vertically and horizontally

Expanded Focus Broader Vertically

Well-being

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Well‐Being is linked to

Lower healthcare costs

Reduced injury

Reduced illness

Lower ratio of absenteeism and presenteeism

Worker, enterprise, and national productivity

Worker Well‐Being

Integrative concept that characterizes quality of life with respect to health and work‐related environmental, organizational, and psychosocial factors.

Five domains: workplace physical environment and 

safety climate; workplace policies and culture;  health status;  work evaluation and experience; and  home, community, and society.

[Chari et al 2018]

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Need for a comprehensive measure

NIOSH Total Worker HealthTM (TWH) defines and operationalizes a framework for achieving worker well‐being

TWH Program designed to support policies, programs, and practices that integrate protections from work‐related safety and health hazards with promotion of injury and illness prevention efforts that advance worker well‐being

NIOSH field testing instrument to measure well‐being domains

How do we measure an expanded view of burden?

This expanded focus will require new skills and competencies for the 

OSH professions.

Will you be ready?

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History of OSH expanded focus 

1833 first OSH focused staff in Britain reporting to Central government

– 4 inspectors ensuring compliance with child labor laws

Late 19th century saw first dedicated OSH staff

– Large and hazardous companies

– Monitoring roles related to inspections and rule compliance 

Development of generalist and specialist OSH professions

– Professionalization of OSH specialties 

– Conflict and questions between professions

– Which profession owns what?

[Hale 2019]

History of OSH expanded focus 

Last 100 years OSH focus expanded from technological base concerned with machinery, chemical safety, and industrial hygiene

– 1920s – human behavior, training, accident prevention, and compliance

– 1950s – ergonomic design

– 1970s – chemical and safety management

Last 50 years OSH professions common in industrialized countries

Many countries now recognize generalist and specialist roles

Companies combining environmental and occupational roles

[Hale 2019]

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ERC graduates by discipline by decade| 1977 – 2017 N=10,668

1048

243332

263

0

1643

494

746

445

16

1259

505 463

336

175

876

408 404 389

623

0

200

400

600

800

1000

1200

1400

1600

1800

Industrial Hygiene Occ. Health Nursing Occupational Medicine Occupational Safety Allied OSH

1977-1986 1987 - 1996 1997 - 2006 2007-2017

TPG graduates by discipline by decade | 1977 – 2017N=7732 

87

274

16 0

170

294

752

154

36

1100

598

771

10830

1242

695

464

142

13

786

0

200

400

600

800

1000

1200

1400

Occupational Safety Industrial Hygiene Occupational Medicine Occ. Health Nursing Allied OSH

1977-1986 1987 - 1996 1997 - 2006 2007-2017

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Personal Risk Factors

Social & Economic Risk Factors

OSHOSH

WorkingLife

Continuum

Personal Risk Factors

OSHSocial & Economic Risk Factors

Traditional OSH skill setsOccupational Medicine & NursingIndustrial Hygiene and Safety Epidemiology, Ergonomics andEngineeringOccupational PsychologyLaw

New skill setsEconomics, Sociology,

Anthropology, Human Relations, Gerontology, Informatics,

Education, Corporate Social Responsibility, Sustainability

Others?

Well-being

Expanded Focus New Skills Sets  

Conclusions and next steps

Protecting the workforce of the future requires a holistic view of the hazards they experience and the range of adverse effects that result

The occupational safety and health field should expand the traditional view of burden to be broader horizontally and vertically

New skill sets are needed to identify and measure an expanded view of burden

OSH research and training should have a futures orientation

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For more information, contact CDC1‐800‐CDC‐INFO (232‐4636)TTY:  1‐888‐232‐6348    www.cdc.gov

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Thank youSFelknor@cdc.gov

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