Health and Wellness Programs for Commercial Drivers (2007)

Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

52.1 Commercial Driving Affects Driver Health Addressing health and wellness concerns for commercial drivers is challenging, in part, because of the varied work environments in which commercial drivers operate. Some drivers may do daily deliveries of goods, while other drivers do short-haul or long-haul (over-the-road) delivery of freight. Bus and motorcoach drivers may drive passengers between distant cities and states or work in the tourist trade where the driver is more likely to usher passengers to tour stops and await completion of the passengers’ tour before making a return trip [for additional differences see CTBSSP Synthesis 6 (Grenzeback et al. 2005) and CTBSSP Synthesis 7 (Brock et al. 2005)]. How often, how far, and how long he/she drives, whether or not the driver works a regular schedule, returns home from an on-duty cycle every day, sleeps in his/her own bed, uses a truck sleeper berth while driving over-the-road, or sleeps in motels, eats regular scheduled meals, eats at home or in fast food restaurants, whether he/she has much opportunity to engage in physical exercise, and so on, all impact a driver’s state of health and wellness. From many aspects, the variety of work schedules of commercial truck and bus drivers is a major contributor to driver health and wellness concerns. Work schedules often may be irregular, involving long and unusual hours, and many drivers spend much time (successive days, even weeks at a stretch) on the road. When describing the myriad of factors involved in assessing commercial driver fatigue, McCallum et al. (2003) listed operational risk factors as including extended work and/or commuting periods; split- shift work schedules; changing, rotating, and unpredictable work schedules; lack of rest or nap periods during work; sleep deprivation and sleep disruption; sleep-work periods conflicting with the body’s biological and circadian rhythms; inadequate exercise opportunities; poor diet and nutrition; and environmental stressors. All of these factors make commercial drivers particularly prone to health problems. A driver’s chosen profession may predispose him/her to many of these health issues. A sedentary lifestyle, lack of good food choices, almost continuous exposure to whole- body vibration while driving, and numerous specific stressors such as driving in bad weather or heavy traffic are all condi- tions that can impact the driver’s health. In many cases, the driver’s chosen profession can lead to physical impairments that ultimately disqualify that driver from that profession. The National Institute for Occupational Safety and Health (NIOSH) uses Bureau of Labor Statistics (BLS) numbers to illustrate the incidence of deaths and injuries by occupation in the United States. For the 10-year period 1992 to 2001, BLS reported 479 fatal occupational injuries for truck drivers. The yearly rate ranged from 17.0 per 100,000 full-time workers in 1993 to a high of 39.2 in 1999. For truck drivers, BLS reported 57,999 nonfatal occupational injuries and illnesses involving days away from work during this 10-year period, and the rates varied from 533 per 10,000 full-time workers in 1992 to 359 in 1998—an average of 5,800 nonfatal cases per year (NIOSH 2004). Commercial drivers must adhere to federal regulations concerning fitness and suitability to drive. The relevant regulations are cited in Section 2.2. 2.2 Federal Regulations for Qualification, Fitness, and Suitability to Drive Physical requirements for commercial drivers are outlined under Title 49 of the CFR 391, the Subpart B, Qualification and Disqualification of Drivers: Paragraph 391.11 General Qualifications of Drivers. The list of requirements includes the following: “A person shall not drive a commercial motor vehicle unless he/she is qualified to drive a commercial motor C H A P T E R 2 Review of the Literature

vehicle.” Under Subpart E, Paragraph 391.41, Physical Qualifications and Examinations, specifies physical qualifica- tions for drivers as follows*: (a) A person shall not drive a commercial motor vehicle unless he/she is physically qualified to do so. . . .” (b) A person is physically qualified to drive a commercial motor vehicle if that person: • Has no loss of a foot, a leg, a hand, or an arm, or has been granted a skill performance evaluation certificate . . .” (follows with additional statements about hand, fingers, arms, feet or legs) • Has no established medical history or clinical diagnosis of diabetes mellitus currently requiring insulin for control; • Has no current clinical diagnosis of myocardial infarc- tion, angina pectoris, coronary insufficiency, thrombosis, or any other cardiovascular disease of a variety known to be accompanied by syncope, dyspnea, collapse, or con- gestive cardiac failure; • Has no established medical history or clinical diagno- sis of a respiratory dysfunction likely to interfere with his/her ability to control and drive a CMV safely; • Has no current clinical diagnosis of high blood pres- sure likely to interfere with his/her ability to operate a CMV safely; • Has no established medical history or clinical diagno- sis of rheumatic, arthritic, orthopedic, muscular, neu- romuscular, or vascular disease which interferes with his/her ability to control and operate a CMV safely; • Has no established medical history or clinical diagno- sis of epilepsy or any other condition which is likely to cause loss of consciousness or any loss of ability to control a CMV safely; • Has no mental, nervous, organic, or functional disease or psychiatric disorder likely to interfere with his/her ability to drive a CMV safely; • Has distant visual acuity of at least 20/40 (Snellen) in each eye without corrective lenses or visual acuity separately corrected to 20/40 (Snellen) or better with corrective lenses, distant binocular acuity of at least 20/40 (Snellen) in both eyes with or without corrective lenses, field of vision of at least 70º in the horizontal meridian in each eye, and the ability to recognize the colors of traffic signals and devices showing standard red, green, and amber; • First perceives a forced whispered voice in the better ear at not less than 5 feet with or without the use of a hearing aid, or if tested by use of an audiometric device, does not have an average hearing loss in the better ear greater than 40 decibels at 500 Hz, 1,000 Hz, and 2,000 Hz with or without a hearing aid; • Does not use a controlled substance identified in 21 CFR 1308.11 Schedule I, an amphetamine, a narcotic, or any other habit-forming drug; • Has no current clinical diagnosis of alcoholism. *For more details see FMCSA website at http://www.fmcsa. dot.gov. 2.3 FMCSA Initiatives Regarding Physical Qualification Standards FMCSA identified several health related areas where its standards are either outdated or lack application of the most current scientific and medical knowledge. The agency acknowledges that there are some cases where there is limited data to link the standards to driver performance and safety outcomes. FMCSA is working to address many of these medical and health related issues. Carriers are advised to track these issues when considering implementing a health and wellness program to ensure that the program addresses FMCSA’s health and driver qualification standards. FMCSA’s initiatives are detailed as follows (current through January 2007). 2.3.1 Medical Review Board Established In March 2006, the Secretary of Transportation appointed five medical experts to serve on FMCSA’s new Medical Review Board (MRB). The MRB will provide science-based guidance for establishing realistic and responsible medical standards during FMCSA’s planned updates to the physical qualification regulations for CMV drivers. Public meetings are planned to report and permit tracking of progress of the MRB. For details consult the FMCSA MRB website at http://www.mrb.fmcsa.dot.gov. 2.3.2 Research Panels Planned To support the work of standards revision and of the MRB’s review, research panels are being planned by FMCSA. 2.3.3 Chief Medical Examiner FMCSA has a plan to appoint a permanent Chief Medical Examiner as a full-time member of the FMCSA staff. 2.3.4 Certified Medical Examiners As part of the SAFETEA-LU Rulemakings under develop- ment, FMCSA issued a Notice of Proposed Rulemaking (NPRM) to establish a National Registry of Certified Medical Examiners (NRCME). The primary mission of the NRCME will be to improve highway safety by producing trained, certified medical examiners who can effectively determine if a CMV driver’s health meets FMCSA standards. 2.3.5 CDL and Medical Certification FMCSA’s proposed merger of Medical Certification and CDL Issuance and Renewal Processes (NPRM) was published 6

in the Federal Register (November 16, 2006, issue, Volume 71, No. 221 pages 66723–66748). The proposal would merge information from a driver’s medical certificate into the CDL process as required by section 215 of the Motor Carrier Safety Improvement Act of 1999. Section 215 of the Act would require interstate CDL holders subject to the physical qualification requirements of the FMCSA to provide a current original or copy of their medical examiner’s certificate to their State Driver Licensing Authority (SDLA). This information would be recorded on each individ- ual’s motor vehicle record (MVR) and subsequently be entered into the Commercial Driver License Information System (CDLIS), the electronic system that contains driver informa- tion for use by licensing and enforcement officials. 2.3.6 Hypertension Standard and Blood Pressure Criteria In 2004, FMCSA revised its standards for monitoring and diagnosing commercial drivers for signs of high blood pressure and hypertension to be more in line with the standards adhered to by the American Medical Association and the World Health Organization. The change in blood pressure (BP) criteria for CMV drivers was from BP < 160/90 to BP < 140/90. 2.3.7 Medical Standards Review On March 7, 2006, FMCSA announced the five medical experts who will serve on the new MRB. FMCSA is planning updates to physical qualification regulations of CMV drivers, and the board will provide the necessary science-based guid- ance to establish realistic and responsible medical standards. FMCSA and its MRB will work through the medical standards update process sequentially. The plans presently include examinations and possible changes to standards regarding diabetes, drug and alcohol, cardiovascular, neurol- ogy, vision, musculoskeletal considerations, and others. 2.3.8 Federal Vision Exemption Program As of January 2007, more than 1,000 active drivers were participating in vision exemptions as part of the FMCSA Vision Exemption Program. Additional clarification and updating of driver vision standards can be anticipated soon. Readers should check the FMCSA website for updated infor- mation on this activity. 2.3.9 Skill Performance Evaluation (SPE) The former Limb Waiver Program, now called Skill Perfor- mance Evaluation (SPE) Certificate Program, has more than 3,400 active driver participants. 2.3.10 Diabetes Standard In March 2006, FMCSA issued an Advance Notice of Public Rulemaking (ANPRM) regarding the Diabetes Standard. FMCSA announced that it is considering whether to amend its medical qualifications standards to allow the operation of CMVs in interstate commerce by drivers with insulin-treated diabetes mellitus (ITDM) whose physical conditions are adequate to allow them to operate safely and without deleterious effects on their health. Additional clarifi- cation of this standard is forthcoming. There has been a significant increase in applications since SAFETEA-LU was enacted. As of September 2006, more than 60 drivers have been approved for the Federal Diabetes Exemption Program. 2.3.11 HOS In response to the federal court ruling of July 2004, FMCSA provided supporting documents to the Final Rule on CMV Driver HOS, and also has forthcoming a set of Omnibus HOS Exemptions. There continue to be issues over the latest HOS regarding the definition of off-duty time, sleeper berth rules, interruptions of sleeper berth periods, and the use of a 34-hour restart counting the HOS rules. 2.4 Most Common Health and Fitness Risks for Commercial Drivers At an occupational health and safety conference held at Wayne State University, Saltzman and Belzer (2007) pointed out that occupational illnesses diminish the quality of life for truck drivers and may lead to premature death. They stated that substantial amounts of additional research are still needed on commercial driver health issues (Saltzman and Belzer 2002, 2007). Conference participants’ concerns about commercial driver health and wellness included • Poor health habits: It is estimated that more than 50% of commercial drivers are regular smokers. Many are obese, lack proper physical exercise, tend to develop chronic diseases such as diabetes at relatively early ages, and may have slightly elevated suicide rates. These points also are documented in studies of truck driver illnesses reviewed and cited by Roberts and York. • Driver injuries: About half of driver injuries involving lost workdays are attributable to sprains, often caused by overexertion such as lifting heavy objects (from Depart- ment of Labor job injury statistics). Most workers’ compensation injuries experienced in the moving, storage, and van lines sector of trucking today are attributable to 7

lifting and awkward posture movements while handling furniture and other items handled in moving and storage work. Studies of drivers loading and unloading cargo (Krueger and Van Hemel 2001) seem to corroborate those at-risk features of many truck driving jobs. • Driver fatigue: Sleep disorders, sleep loss, sleepiness, and driver fatigue from long and irregular work hours increase risks of operational errors, unsafe driving, injuries, and deaths. The NTSB, FMCSA, the American Trucking Asso- ciations, numerous safety advocates and the fatigue research community have documented extensively the issues and research surrounding commercial driver fatigue [see for example the review of many of these issues in CTBSSP Synthesis 9 by Orris et al. (2005); and extensive amounts of research on commercial driver cited on FMCSA’s website]. • Driver illnesses: Work-related environmental exposures (e.g., to diesel exhaust, other toxic fumes, continuous noise, and whole-body vibration) may be associated with chronic respiratory diseases, reductions in pulmonary function, lung cancer, allergic inflammation, hearing loss, musculoskeletal injuries, lower back pain, and other con- ditions which can have driving safety implications (Saltz- man and Belzer 2007). These same health risks were raised by Public Citizen in two successive federal court law suits (2004, 2005) as part of the continuing appeals of the newer HOS rules for truck drivers. A chapter in Transportation Research Circular E-C117 (Knipling 2007) produced by the Truck and Bus Safety Com- mittee (ANB70) outlines numerous health and wellness issues related to commercial driver safety (Krueger et al. 2007). Taken together, the chapter in the TRB circular, along with the CTB- SSP Synthesis 9 (Orris et al.) and the FMCSA-ATRI Gettin’ in Gear wellness program for commercial drivers (Roberts and York; Krueger and Brewster 2002) identify the most important and common risks to commercial driver health and fitness. • Regular tobacco use. It is generally believed that more than 50% of commercial truck drivers are regular tobacco users (Korelitz et al. 1993)—about double the national average of smoking adults in the United States (Substance Abuse and Mental Health Services Administration-Office of Applied Studies [SAMHSA-OAS] 2007). It is estimated that an employee who smokes costs an employer at least $1,000 extra per year in total excess direct and indirect health care costs (American Lung Association 2003). In the Stoohs et al. (1993) study of sleep apnea and hypertension with 125 truck drivers working for one company, 49% were smokers. The percentage of bus and motorcoach drivers who regularly use tobacco is generally believed to be slightly lower than that of truckers because of smoking restrictions inside passenger buses. Anecdotal reports from bus drivers indicate many bus and motorcoach drivers, as a result of such restrictions, have quit smoking altogether. • Being overweight and experiencing obesity. A survey of 3,000 commercial truck drivers in 1993 indicated more than 40% were overweight and 33% were obese. Both figures are con- siderably higher than national averages (Korelitz et al.). No current accurate figures were obtained on the incidence of obesity in commercial drivers. • Hypertension or high blood pressure. FMCSA recently revised CFR Part 391 standards for hypertension to con- form to those of the American Medical Association (AMA) and the World Health Organization (WHO). Now a driver with BP > 140/90 mmHg is deemed to have hypertension. If not treated, hypertension can lead to heart disease, renal failure, and stroke. No current incidence of hypertension figures was found for CMV drivers. However, the Korelitz et al. survey found 33% of drivers had BP > 140/90 and 11% had BP > 160/95. Such percentages indicate there is considerable room for improvement and add to the ration- ale that commercial driver health programs must focus on monitoring and preventing hypertension. • Poor eating and drinking habits, inadequate diet and nutrition. Many truck drivers admit to eating only one or two meals per day instead of the recommended three. Favorite main courses for meals on the road are still steaks and burgers, and many drivers eat numerous “junk food” snacks each day (Korelitz et al.). Few commercial drivers eat five or more servings of fruits and vegetables per day as recommended by the National Cancer Institute. Truck stop food choices tend not to be conducive to good nutrition. • Lack of physical activity and proper exercise, degrading states of physical fitness. Low physical activity is a major public health issue despite the considerable health benefits that can be gained from regular activity (Kelly 1999). Most long-haul drivers do not exercise regularly. Roberts and York reported that only about 10% of commercial drivers regularly participate in aerobic exercise; however, most attendees at the FMCSA-ATRI Gettin’ in Gear course offerings expressed much doubt that figures of regular aerobic exercisers are even that high. • Use and abuse of alcohol and other chemical substances, including misuse of prescription and non-prescription med- ications and drugs, diet pills, antihistamines, sleeping pills, energy drinks, and alleged nutritional food supplements. As a result of the implementation of randomized drug testing in the CMV work force and the threat of loss of employment if illicit drug use is detected, currently there does not appear to be a large problem with use and abuse of illicit drugs in the U.S. commercial driver population; however, no accu- rate figures on this problem were identified in this survey. 8

Figures on the use of alcohol and alcohol abuse also are not well-known in either the trucking or bus/motorcoach industries. Many drivers do not understand the impact a variety of other chemical substances have on health and driving performance. More research and education are needed on the performance and interactive effects (especially interactive effects) of prescription drugs, self- medications, and over-the-counter remedies such as antihistamines, diet pills, and nutrition supplements. 2.5 Health Issues That May Affect Commercial Driver Safety While these driver health risks can impact highway safety, many of the readily identifiable effects are more apparent on drivers’ quality of life and life expectancy (Husting 2006). Husting and Biddle outlined how commercial driving fits the Public Health Model, stating that motor vehicle safety is an important public health problem particularly involving commercial drivers. Solomon et al. (2004) point out that the workplace of commercial drivers is the community, and thus the health of commercial drivers is of special interest. Several studies suggest an association between illnesses among com- mercial drivers and the increased likelihood of fatal motor vehicle crashes with other drivers among the general public (NTSB 1990; Solomon et al.; Stoohs et al. 1994; Dionne et al. 1995; McCartt et al. 2000; Hehakkanen 2001). In a September 2006 review, a Joint Medical Association Task Force provided recommendations on sleep apnea screening for commercial drivers indicating the medical research they reviewed suggests obstructive sleep apnea is a significant cause of motor vehicle crashes (resulting in a twofold to sevenfold increase in risk) and increases the possibility of an individual having significant other health problems (Hartenbaum et al. 2006). 2.5.1 Cardiovascular and Heart Disease Cardiovascular disease, a leading cause of heart-related ill- ness and sudden death in the general population also impacts the health and safety of a growing number of commercial drivers in the United States (Rafnsson and Gunnarsdottir 1991; Bigert et al. 2003; Blumenthal et al. 2002). Only a few published studies directly address cardiovascular disease (CVD) as it affects truck and motorcoach drivers, and they provide mixed statements of its incidence and risks (Rafnsson and Gunnarsdottir; Bigert et al.; Blumenthal et al.; Robinson and Burnett 2005; Luepker and Smith 1978; Murphy 1991). Ruan Transportation Management Systems in Des Moines, Iowa, determined that during the 3 years of 1990 to 1992, heart problems appeared in the top two most expensive health care cost categories each year, and that more than 10% of the company’s total health care costs were related to heart disease. Truck drivers had most of the company’s heart claims and had a tremendous impact on Ruan’s employee benefit costs (Cleaves 1998; Holmes et al. 1996). Commercial drivers experience a unique constellation of risk factors for CVD involving lifestyle factors (i.e., poor diet, sedentary jobs, and smoking) combined with worksite factors such as long hours, vigorous exertion, strict road rules, stress, fatigue, and potential exposure to high noise levels, diesel fuel combustion exhaust, carbon monoxide, lead, freon, and the vast array of substances carried as cargo (Robinson and Burnett). Many factors common among truck drivers (elevated blood cholesterol, high blood pressure and hypertension, dia- betes, being overweight, lack of aerobic exercise, and tobacco use) contribute to chronic and acute cardiovascular illness that could lead to myocardial events while driving (Cox 1998; Roberts and York). As an example of this, an NTSB study of crashes involving truck driver fatalities reported 19 of 185 fatally injured truck drivers (10%) had such severe health problems that NTSB pinpointed health as a major factor in or the probable cause of the crashes (NTSB). Seventeen of those 19 crashes (89%) involved a form of cardiac incident at the time of the accident (e.g., sudden incapacitation of the driver due to an acute heart problem). 2.5.2 Diabetes During the past two decades, diabetes has become one of the most important public health problems—a consequence of increasing awareness and a dramatic increase in the number of people who receive a diagnosis of type 2 diabetes (Mantzoros 2006). Diabetes mellitus is a disease in which the body does not produce sufficient insulin, or does not metabolize glucose in the normal way, leading to metabolic changes that can have adverse effects. Diabetics have increased occurrence of eye disorders, kidney disease, arteriosclerosis, and heart disease. Poor circulation in the feet and legs attributable to diabetes leads to problems with peripheral nerves and vasculature of the extremities. One safety concern is that hypoglycemic episodes caused by diabetes may affect a person’s ability to drive. These episodes manifest through either loss of consciousness or disorientation, or from end-organ effects on vision, the heart, and particularly the feet. The main safety concern for insulin- dependent drivers is the possibility for unexpected occurrence of hypoglycemic reactions that cause drowsiness, impairment of perception or motor skills, abnormal behavior, impaired judgment (which may develop rapidly and result in loss of control of the vehicle), semi-consciousness, unconsciousness (diabetic coma), or insulin shock. Laberge-Nadeau et al. (1996) found CDL holders for single- unit trucks, who were diabetic, but without complications and 9

not using insulin, had an increased crash risk of 1.68 (i.e., 68% increased risk) compared with healthy CDL holders. As a result of irregular work schedules, rotating shifts, and night work that many commercial drivers experience, these drivers frequently experience circadian desynchronosis, a form of work shift lag (Comperatore and Krueger 1990) whereby normal circadian physiological functioning also shifts, some- times affecting other biological functions. Irregular work hours and resultant chronobiological considerations are important for diabetics and are especially critical for shift workers. Lack of sleep, fatigue, poor diet, emotional condi- tions, stress, and concomitant illness compound the problem by affecting the self-regulatory hormones that keep the blood glucose levels within normal limits. Commercial drivers who are diabetic need competent medical treatment and prescribed protocols for use of medications. These drivers must follow precautionary steps to avoid hypoglycemic episodes. Diabetic drivers must comply with specified periodic diabetes reviews by medical specialists; eat regularly timed carbohydrate-balanced meals to keep glucose levels within normal or desired limits; monitor blood glucose levels; carry supplemental glucose in the vehicle; and should stop driving immediately if a hypoglycemic episode occurs. As mentioned in Section 2.3, FMCSA currently has an active program in place to grant certain exceptions to dia- betic drivers and also to perform in-depth medical review of current research and insulin treatment practices for diabetics. 2.5.3 Hearing and Hearing Impairments An important safety consideration for drivers of commer- cial vehicles is the degree of responsiveness to critical events, particularly in crash-likely circumstances which call for employing defensive and evasive driving maneuvers. CMV drivers require a reasonable level of hearing to ensure their awareness of changes in engine or road noises that may signal developing problems. Drivers need good hearing awareness to respond to oncoming and overtaking traffic, to horns, to railroad crossings, and the signals and sirens of emergency vehicles. There is no medical requirement for commercial drivers to be able to communicate well through spoken word. Commu- nication requirements of a specific job may preclude such a driver from working for a particular employer, but medical criteria do not preclude certification for a CDL. As noted in Section 2.2, FMCSA currently requires all persons seeking a CDL to possess a certain minimal level of hearing. Hearing criteria in 49 CFR 391.41 (b) (11) state that a CMV driver cannot have an average hearing loss in the better ear greater than 40 decibels at 500 Hz, 1,000 Hz, and 2,000 Hz with or without a hearing aid or must be able to perceive a forced whisper from no less than 5 feet away. This actually means drivers with substantial amounts of hearing loss may be permitted to drive commercial vehicles. Most people with a significant hearing loss are aware of their disability. Hearing loss is gradual and insidious, and so people with mild hearing loss mostly are not aware of it. A driver with mild hearing loss often is able to compensate for his/her impaired hearing, even without wearing hearing aids, by being more cautious and relying more on visual cues. A moderate to substantial hearing loss does not appear to adversely affect a driver’s ability to drive safely when that driver compensates for his/her hearing loss by wearing pro- fessionally fitted hearing aids. After extensive literature review on topics related to hearing and driving, Robinson, Casali, and Lee (1997) estimated appropriate hearing levels required in driving commercial vehicles and evaluated methods to test drivers’ hearing. Results indicated some truck driving tasks require continual use of good hearing; that truck drivers could potentially suffer hearing loss from noise exposure; and that truck-cab noise in the 1990s model trucks studied compromised the intelligibility of live and CB speech, as well as the audibility of internal and external warning signals. Robinson, Casali, and Lee recom- mended several truck cab and warning signal design changes. In a field study to relate driver exposure to continuous acoustical noise to hearing loss, Seshagiri (1998) assessed the noise exposure in truck cabs by taking more than 400 meas- urements to determine the ambient noise levels to which truck operators are exposed while taking lengthy drives. Seshagiri took noise measurements at the driver’s head position in a variety of trucks (in long-haul, pickup and delivery, and sleeper berth truck samples) while drivers operated in a variety of driving conditions. Seshagiri found the noise exposures of 10% of the long-haul drivers tested exceeded 90 dB(A) while 53% of the average noise levels exceeded 85 dB(A). Seshagiri’s measurements indicate that some truck drivers, at least some of the time, incur a significant noise exposure risk to their hearing depending on the operating conditions, in particular when they routinely drive with the driver’s side window open and have the radio turned to a relatively high volume. The risk of hearing loss among drivers of repeated long- duration trips is therefore a health concern. While many newer truck cabs on the road today claim to have been designed to be quieter, there are no reports of recent acousti- cal noise measurements taken at the driver’s head position in Class 8 trucks. Because OSHA now promulgates workplace noise exposure limits approximating 85 dB(A) at the opera- tor’s head position, perhaps the 49 CFR 393.94 should be re-evaluated for sustained periods of truck driving and additional measurements of ambient noise in current truck 10

models should be collected and evaluated. There is also a need to develop an audiometric database for truck drivers, and presumably for bus and motorcoach drivers, and to continue assessment of the validity and in-practice application of the forced-whisper test, as well as to continue evaluation of active noise control systems (Maguire 2003, 2005) which can be used to reduce acoustical noise threats to the hearing of commercial drivers. 2.5.4 Vision Considerations Safe and proper operation of motor vehicles requires excel- lent vision, in terms of visual acuity, breath of visual field, and color vision. Good visual acuity is required for many driving tasks. A significant loss of visual acuity or loss of visual fields diminishes a person’s ability to drive safely. However, the level of vision necessary for safe driving has been a con- tentious issue because of the unavailability of definitive empirical evidence on which to base a clearly defensible visual performance standard (Decina and Breton 1993). It is gener- ally accepted that a driver with uncorrected visual defects (i.e., without prescription lenses) may fail to detect other vehicles, pedestrians, or roadside barriers, may take appre- ciably longer to read road signs at a distance or at night, and therefore may be slow to perceive and react to hazardous situations. Fortunately, prescription lenses can compensate for most forms of degraded visual acuity to permit most drivers to have adequate visual acuity for driving. Since the federal government began regulating vision stan- dards for motor carriers in interstate commerce during the late 1930s, the purpose of setting vision standards for drivers of commercial vehicles has been to identify individuals who represent an unreasonable and avoidable safety risk if allowed to drive CMVs. Federal regulations, specifically those covered by 49 CFR 391.41 (b) (10), require a driver to have distant visual acuity of at least 20/40 (measured via Snellen eye chart test) in each eye with or without corrective lenses, or visual acuity separately corrected to 20/40 (Snellen) or better with corrective lenses; and distant binocular acuity of at least 20/40 (Snellen) in both eyes with or without corrective lenses. Recently, laser eye surgery techniques have proliferated for vision corrections; however, laser surgery can be associated with several effects that bear on driver safety, including that of commercial drivers who have recently had laser eye surgery. According to the U.S. Food and Drug Administra- tion (FDA) Center for Devices and Radiological Health (2006) some patients who have had laser eye surgery have instability of visual acuity, which may decline during the waking hours. After undergoing this procedure some drivers may have different visual acuity at different times of the day, worsening by as much as two lines of the Snellen chart (which could result in visual acuity not meeting medical guidelines). Additionally, some people who undergo the vision correcting eye surgery procedure known as Lasik (laser-assisted in-situ keratomileusis) may experience glare, halos, and starbursts around lights at night, which could be troublesome while driving. The effects may take a few months to disappear. The vision medical guideline does not address these issues. It is not known how many commercial drivers undergo increas- ingly popular laser eye surgery for vision corrections. More research is needed on this set of visual issues relating to laser surgery outcomes. An aging driver population experiences vision changes associated with age, most particularly cataracts. Cataracts are opacities of the lens attributable to a biochemical change in structure in the eye. People with cataracts experience more glare, particularly at night when the headlights of oncoming traffic reflect off the cataract before hitting the retina. This results in loss of visual acuity and could result in difficulty perceiving the driving environment. Testing for this condi- tion is available, but not required in the Commercial Driver Examination (U.S. DOT vision medical standard). More research on the effect of cataracts and driving performance is warranted. An adequate visual field is important for driving, and peripheral vision is particularly important in tasks such as changing lanes, merging into a traffic stream, or detecting pedestrians about to cross into traffic. Severely restricted visual fields impair driving performance and can increase crash risk (Johnson and Keltner 1983; Wood and Troutbeck 1992, 1994; Coeckelbergh et al. 2004). U.S. DOT standards 49 CFR 391.41 (b) (10) require commercial drivers to have fields of vision of at least 70 degrees in the horizontal meridian in each eye. Decina and Breton suggest that this aspect of the standards should be revisited because the field-of-view of a normal healthy adult is closer to 140 degrees for each eye. Visual field losses can result from eye diseases such as retinitis pigmentosa (inherited degeneration of the retina causing significant visual field loss, often by age 30), or con- ditions such as glaucoma, optic atrophy, retinal detachment, or localized retinal or choroidal infection. Visual fields can also be reduced by head trauma, brain tumor, stroke, or cere- bral infection. Good rotation of the head and neck is also nec- essary to ensure an adequate field of vision. Drivers generally need good color vision for some driving tasks. CFR 49 391.41 (b) (10) requires a driver to recognize the colors of traffic signals and devices showing standard red, green, and amber. A driver with red-deficient vision would have some difficulty detecting and relating to red traffic lights at road intersections and in seeing rear braking lights on other vehicles. In effect, he/she would have to rely on see- ing the brightness of the lights rather than the red color. However, there is no solid evidence that color-blind drivers are less safe drivers. Recent improvements in traffic sign 11

engineering to modify the hue and intensity of traffic lights help persons with red deficiency. Decina and Breton point out that the color requirement does not exclude red-green color defective drivers because the standard does not provide adequate instruction on requirements for color vision test- ing. They also stated that it is doubtful that the standard intended to exclude typical red-green color defective drivers because these drivers are currently on the road and there is a lack of evidence that their safety record is worse than the records of those without such color vision defects. One of the problems with the standard is the lack of an adequate description of the specificity of testing stimuli, lighting con- ditions, equipment, or uniformity of testing procedures (Decina and Breton). This area too might warrant some additional research. Dark adaptation is important for night driving. “Night blind drivers” do not adapt well to darkness, can become involved in night driving crashes, and may need to be restricted to daytime driving activities. Driver testing does not check for night blindness conditions. Persons with progressive eye conditions such as cataracts, glaucoma, diabetic retinopathy, optic neuropathy and retini- tis pigmentosa require counseling by appropriate medical authorities and periodic checkups to determine if their eye conditions have worsened and progressed to the stage where they should no longer drive for safety reasons (Coeckelbergh et al.). Commercial drivers with such conditions may require encouragement to select another form of employment. Their vision should be monitored regularly, and when their loss of acuity or loss of visual fields is such that they are no longer safe to drive, they should surrender their CDLs and other driving licenses as well. If visual criteria are used to determine fitness to drive, sensitivity and specificity of the vision tests should be high. However, as Coeckelbergh et al. point out, numerous studies cited in the literature suggest that although the relationships between vision requirements and driving safety are signifi- cant, they are not conclusive with regard to the identification of individual at-risk drivers (Ball et al. 1993). For more information, see Visual Disorders and Commercial Drivers at http://www.fmcsa.dot.gov/rulesregs/ medreports.htm. 2.5.5 Sleep Disorders and Resultant Driver Fatigue Sleep disorders can deprive drivers of restful and restora- tive sleep in the necessary quality and quantity. Sleep disorders, all of which have independent health conse- quences, often lead to driver fatigue and loss of alertness while driving, thereby negatively affecting driving safety. Some sleep disorders particularly relevant to commercial drivers include insomnia, sleep apnea, drug-dependency insomnia, restless leg syndrome, delayed or advanced sleep phase syndrome, and narcolepsy. Krueger et al. (2007) provide a short explanation of each of these important sleep maladies. Sleep disorders individually are of concern because of the medical and health conditions associated with them. Obstructive sleep apnea, for example, interacts with inde- pendent related health risks involving respiratory, cardiovas- cular, and circulatory problems and increases the possibility of an individual having significant health problems such as hypertension, stroke, ischemic heart disease, and mood disorders (Hartenbaum et al.). For commercial driving safety, however, the resultant driver fatigue and adverse affects on commercial driver alertness on the road present the greatest concerns. Sleep disorders such as sleep apnea are diagnosable, treatable, and generally partially manageable for commercial drivers. There is an extensive literature on sleep apnea and its relationship to commercial driving (see Pack et al. 2000, Pack et al. 2002, and the FMCSA and National Sleep Foundation websites for some of this coverage). Through the efforts of the National Sleep Foundation, the FMCSA, and various safety- oriented groups, as well as sleep research groups, motor carriers have become increasingly more aware of sleep disor- der issues. Perspectives on sleep disorders, especially sleep apnea, have changed in the past decade. Some carriers have begun to develop sleep disorder countermeasures as a part of employee wellness programs. They provide medical screening for sleep maladies and provide for diagnosis and treatment (see the Schneider National case study in Section 4.1). The goal is to retain valuable, experienced drivers even as the driver receives treatment for sleep maladies. On September 12, 2006, a joint task force of the American College of Chest Physicians (ACCP), the American College of Occupational and Environmental Medicine (ACOEM), and the National Sleep Foundation released a set of new recom- mendations they claim offers an updated and consistent approach to the screening and management of obstructive apnea (OSA) among CMV operators (Joint Task Force press release, September 12, 2006; Hartenbaum et al.). This important Joint Task Force statement provides an updated description of sleep apnea, and bases its recommendations on an extensive review of the latest sleep apnea research and existing medical guidelines related to OSA from the U.S. DOT agencies. Readers will note that the research team chose not to cover the overall topic of commercial driver fatigue in this synthesis because this important topic is adequately covered in numerous other printed reports (for example, CTBSSP Synthesis 9 [Orris et al.]) and because many driver fatigue issues are more related to driving performance than they are 12

to “health concerns” per se. However, readers interested in worker fatigue as it relates to health issues might want to review a recent occupational medicine article by Ricci et al. (2007). They reported worker fatigue in the United States carried overall estimated costs of more than $136 billion per year in health-related lost productivity—$101 million more than for workers without fatigue (84% of the costs were related to reduced performance while at work, rather than absences). 2.6 Additional Driver Health Conditions That May Affect Driving Safety 2.6.1 Obesity Obesity refers to maintaining an excessive amount of body fat or excess storage of energy in adipose tissue. It is generally defined as a body weight greater than 5% more than the “ideal body weight” (average) for specific height and gender categories (McArdle et al. 1991). Medical personnel can readily identify health-related concerns for obesity in com- mercial drivers. They include a well-established risk factor for cardiovascular disease, hypertension, diabetes, or stroke (Roberts and York), and for obstructive sleep apnea (Pack et al. 2000; Pack, Dinges, and Maislin 2002). Obesity, or even being slightly overweight, exacerbates conditions of arthritis, back pain (particularly lower back pain), and other MSDs such as carpal tunnel syndrome (Miyamoto et al. 2000). Obesity also increases the risk of cancer when it accompanies other health-related conditions such as low activity levels, diabetes, or recent menopause. The AMA published “Assessment and Management of Adult Obesity: A Primer for Physicians” (Kushner 2003) in an attempt to encourage physicians to accentuate health promotion and disease reduction issues involving obesity. Research literature specifically relating obesity to driver safety and performance is scant and difficult to locate. Being substantially overweight and unable to maintain a healthy body weight and body fat levels interacts with a driver’s ability to maintain overall physical fitness and at least indirectly impacts on a driver’s ability to continuously maintain a safe driving posture and practices. In surveying 3,000 truck driv- ers, Korelitz et al. noted 73% were either overweight—body mass index (BMI) between 25 and 30—or obese—BMI greater than 30. Stoohs et al. (1994, 1995) reported a direct dose-dependent relationship between BMI and driver crash- likelihood. Obesity is often accompanied by obstructive sleep apnea, thereby contributing to driver fatigue. Stoohs et al. (1993) reported the prevalence of sleep apnea in 125 drivers working for one company they surveyed. Of those drivers with sleep apnea, 71% were borderline obese (i.e., defined as BMI > 28 in their study). The relationship between obesity and sleep apnea is a cause of health and safety concern among truck drivers because of the prevalence of obesity in this population. Obesity in the workforce is also of concern to employers who are interested in cutting down on workplace injuries and workers’ compensation claims that might be in part attributable to a worker’s overweight condition—seemingly a particular problem in the truck driver population of the United States. Since the 1960s, major changes in employ- ment protection in the form of antidiscrimination laws, such as the Americans with Disabilities Act (ADA), make it tougher for employers to enforce employee physical and weight standards, unless a person simply is unable to perform his or her job (Carpenter 2006). 2.6.2 Hypertension Hypertension or high blood pressure is a chronic disease affecting more than 50 million people in the United States. High blood pressure increases an individual’s risk of heart disease, renal failure, and stroke (David et al. 1996). Hyper- tension is called the “silent disease” or “silent killer” because there is no clear warning sign to an individual that he or she might have high blood pressure. It is very important for people to have their blood pressure measured and monitored from time to time, because they might have hypertension and not know it for months or years. Excess body weight correlates closely with increased blood pressure, and the survey work by Roberts and York found that almost every prospective study of factors that influence blood pressure regulation identified weight as the strongest predictor of blood pressure. David et al. estimated that in almost 50% of adults whose hypertension is managed through pharmaceuticals, the need for drug therapy could be alleviated with only modest reductions in body weight. In addition to the Korelitz et al. data cited in this report, there are other indicators that hypertension is a problem of considerable magnitude in the truck and bus driver commu- nities. An insurance industry study (Harrington 1995) indicated that 20% of the drivers in one of the test groups had high blood pressure. Evans (1994) reported that a large cross- sectional study of black and white male bus drivers in San Francisco revealed elevated rates of hypertension compared with a national sample of similar individuals. This study also noted the prevalence of hypertension increased with length of employment. Evans also reported a Norwegian study comparing male bus and truck drivers to industrial workers and noted a stronger correlation between length of employment and elevated blood pressure among commercial vehicle drivers 13

(Evans). The Stoohs et al. (1993) sleep apnea study reported 17% of the truck drivers in that 1993 study had blood pressures measuring greater than 160/95 mmHg. Contributing factors to hypertension include high cholesterol, obesity, and lack of exercise (West 2001). Uncon- trolled hypertension is the primary diagnosis for up to 25% of individuals with chronic kidney failure and can also be a major cause of strokes. Hypertension is very prevalent in African Americans and, according to the American Heart Association, up to 30% of all deaths in African American men can be attributed to hypertension. Fouad et al. (1997) describe the city of Birmingham, Alabama, as having almost 50% African American employees in their workforce, and therefore tailor their educational programs to target reduc- tions of hypertension as a significant part of health promotion. The program produced marked drops in blood pressure measures and demonstrated that a culturally appro- priate, educational program, focused on employees known to be at high risk, may increase control of hypertension. Hypertension, obviously one of the principal health risks to commercial drivers, is discussed at length in the FMCSA- ATRI Gettin’ in Gear train-the-trainer course (Krueger and Brewster). Course information for drivers stresses that: unlike vehicle diagnostic systems on trucks and buses, the body has no ready made gauge to tell a person he or she has high blood pressure. One of the easiest health and wellness suggestions to implement which is offered in that course is a suggestion for employers to acquire automated blood pres- sure monitoring cuffs/kits for their employees, especially so for their drivers. These can be purchased at almost any local drug store for approximately $50. The employer is then told to place the blood pressure monitors into the drivers’ day room or gathering place. They are also told to provide a basic amount of information about blood pressure and hyperten- sion (a supply of trifold brochures on blood pressure helps); and then suggest that from time-to-time their drivers meas- ure their own blood pressure and keep track of it in a personal diary for several consecutive weeks. If the drivers sense that they have suspiciously high blood pressure they should be encouraged to seek medical attention and advice. 2.6.3 Poor Nutrition, Eating Habits, and Diet It is a widely held belief that commercial drivers, both truck and bus/motorcoach drivers, do not usually adhere to healthy eating habits, and therefore their daily diet and nutritional needs are identified as a health and wellness concern (Roberts and York; Krueger and Brewster; Holmes et al.). The reasons for this concern include the fact that many commercial driv- ers are “continually on the go” driving from place to place. They consume much of the food they eat at “fast food restau- rants” or out of coin-operated vending machines and do not maintain a regularly scheduled nutritional diet program for themselves. For example, Holmes et al. studied 30 drivers in what they described as a prototypical wellness program. They pointed out that the drivers’ favorite meal items while on the road were steak and burgers. The typical snacks the drivers ate included chips, fruit, candy, donuts, and cookies, and only 15% of the drivers ate five or more servings of fruits and veg- etables per day as the National Cancer Institute recommends for preventive health purposes. In the Korelitz et al. survey of almost 3,000 truck drivers attending a trade show, more than 80% of these drivers ate only one or two meals per day, and 36% had three or more snacks per day. Roberts and York cited Dr. C. Everett Koop, who noted that 8 of the 10 the leading causes of death are related to what people eat. From heart disease to cancer, the food people eat has an influence on whether many chronic diseases develop. A healthy nutritious diet is among the most important influ- ences on an individual’s health. However, “bad habits” (eat- ing junk food, etc.) are among the hardest habits to change. Gettin’ in Gear points out that tracking one’s progress toward smoking cessation may simply be a somewhat easy matter of counting the decreasing number of cigarettes one smokes each day/week to gauge the degree of success one is having in smoking cessation. However, in terms of improv- ing nutrition, determining how much one consumes by counting calories, proteins, carbohydrates, vitamins, miner- als, and numerous other nutritional measures is considerably more difficult, because it requires a basic understanding of nutrition, the contents of food items consumed, and paying constant attention to the numbers—at least until healthy eat- ing becomes a good habit. Today, there is no shortage of nutritional information for the American consumer. This information includes books on the topic, newspaper, magazine, and website generated help- ful hints, improved labeling of the content and nutritional value of many consumable foods, the Department of Agricul- ture’s latest food pyramid (which is difficult to understand and use and seemingly requires access to computer descrip- tions of the details), the American Heart Association’s Healthy Heart symbols displayed on various restaurant menu items, and extensive lists of the contents of foods at many restaurants (including those provided in popular fast food restaurants). The Gettin’ in Gear training program begins the educational process for commercial drivers with plenty of insights on how to proceed (Roberts and York; Krueger and Brewster). 2.6.4 Sedentary Lifestyle: Lack of Physical Fitness There is plenty of medical and epidemiological research evidence to illustrate the value of physical activity, especially 14

in the form of physical exercise, to reduce the risk of many diseases, including cardiovascular and heart disease, hyper- tension, osteoporosis, diabetes, and breast and colon cancer, as well as reducing the risk of psychological illness such as depression, anxiety, and stress (Harig et al. 1995; Barko and Vaitkus 2000; McArdle et al. 1991; U.S. Department of Health and Human Services, Healthy People 2000; Lakka et al. 1994). A sedentary lifestyle, generally defined as one in which a per- son exercises less than once per week, is at least partially responsible for one-third of the deaths in the United States due to coronary heart disease, colon cancer, and diabetes (Lakka et al.; U.S. Department of Health and Human Services, Healthy People). It is estimated that about 30% of total deaths and 30% of total loss of disability-adjusted life years in the WHO Euro- pean Region are related to environmental and lifestyle factors which might be controlled or at least influenced through health protection and promotion activities undertaken at the work- place (Kelly). It is further estimated that physical inactivity is responsible for about 7 to 11% of deaths and 3 to 5% of total loss of disability-life years (Murray and Lopez 1996). Western European health and physical fitness figures are paralleled by many statistics in U.S. health industries. With a preponderance of irregular driving schedules, many commercial drivers, both truck and bus/motorcoach drivers, find it difficult to schedule time to do regular physical exercise. Fifty percent of the truck drivers in the Korelitz et al. survey of almost 3,000 drivers at a tradeshow said they never participated in “aerobic” exercises and only 8% of these drivers “regularly” participated in aerobic exercise. On the other hand, Halvorson (2002) found that regular exercisers at a company’s onsite fitness center achieved higher job performance ratings, stayed longer with the company, had lower medical and prescription claim expenses, and had lower absenteeism rates than those who did not exercise. Exercisers lost an average of 20.9 hours of work (per quarter) compared with 36.6 hours for non-exercisers. As with the difficulties in getting commercial drivers to eat nutritious meals, encouraging them to take opportunities to do regular scheduled physical exercises is tough. Having or making the time to do regular exercise is a chronic problem for many commercial drivers. A favorite line from one long- haul truck driver often quoted in the Gettin’ in Gear course is: “let me understand doc, I get off work about 3 a.m. and you expect me to go to the local gym and do what?” In the Gettin’ in Gear program, long-haul drivers are encouraged to capitalize on the opportunity to do 20 to 30 minutes of phys- ical exercise during their now mandatory 10 hours off-duty time since most people do not sleep for 10 hours straight. Numerous hints on how to prepare for and obtain necessary amounts of physical exercise both at home and while on the road, including identification of simple exercise equipment that can be carried in one’s truck or bus, are provided in the Gettin’ in Gear course materials (Krueger and Brewster; and see also Kelly; Cox 2003). 2.6.5 Musculoskeletal Disorders (MSDs), Low Back Pain, Neck Pain, Other MSDs, and Cumulative Trauma Disorders (CTDs) The U.S. Department of Labor’s Bureau of Labor Statistics (BLS) states that in the year 2004 there were a total of 1.3 mil- lion injuries and illnesses in private industry requiring recuperation away from work beyond the day of the incident. Four of 10 injuries and illnesses were sprains or strains, with most of these stemming from overexertion or falls on the same level. BLS also points out that in 2004, heavy-truck and tractor-trailer drivers suffered 17,770 MSDs, which was third highest among U.S. workers. Of the occupations with 0.75% or more of the total days away from work cases, drivers of both heavy trucks and tractor-trailer trucks, as well as light or deliv- ery truck drivers, had the highest median number of days away from work (12) because of illness and injury of all the occu- pations tracked. (See BLS: “Lost Work Time Injuries and Illnesses, 2004” www.bls.gov/news.release/pdf/osh2.pdf. ) Insurance industry figures on workers’ compensation perennially reflect numerous injuries for truck drivers as being involved with not only musculoskeletal injuries (such as low back pain), but neck, arm, shoulder, leg, and knee injuries (personal communication with Martin Lesko, Loss Prevention Manager at Vanliner Insurance Co., September, 26, 2006, at Dallas, TX). Obesity, or even being slightly overweight, is a large contributor to those injury statistics, as obesity can exacerbate conditions of arthritis, back pain, especially low back pain (Miyamoto et al.) and other MSDs such as carpel tunnel syndrome. Magnusson et al. studied the prevalence of back pain among 40 bus and 40 truck driv- ers, noting that 55% of the truck drivers were overweight. Truck drivers notoriously lead a sedentary life style (exer- cise less than one time per week) and their overall level of physical fitness is known not to be good, with large numbers of commercial truck drivers at least, bordering on being unfit. The picture for commercial bus and motorcoach drivers is less clear, because not much analytical data on their fitness levels was located. A Danish study in 1996 found almost all men in occupations involving professional driving had statistically significant elevated risks of being hospitalized with prolapsed cervical intervertebral disc (Jensen et al. 1996). In comparing occupa- tional risk factors, in 2003, the WHO listed the risks of experiencing low back pain by drivers of buses, trucks and tractors at a risk score ranging from 1.83 to 5.49 relative to a baseline risk of 1.0 for office clerical workers (Concha- Barrientos et al. 2003, pp. 1750 and 1784). The data source for 15

low back pain in this WHO report seems to have been data quoted from Bovenzi and Betta (1994). A literature review by Teschke et al. (1999) cited such factors as working postures, repeated lifting, heavy labor, previous back pain, and stress- related factors including job satisfaction and control, body condition, and weight (all associated with lengthy driving, at least some of these risks affect many truckers) as contributing to the incidence of back pain and back disorders in a work- force. Simple biomechanics explains why the human body’s natural curvature of the spinal column (lordosis) means that humans are not meant to remain in a seated posture for hours at a stretch, as the spinal fluid in the spinal column itself compresses over time while seated (Bhattacharya and McGlothin 1996). Teschke et al.’s data support a causal link between back disorders and driving occupations and whole-body vibration. Cann, Salmoni, and Eger (2004) highlight some of the contributions to back discomfort which can be attributed to whole-body vibration. At least, each of the major manufac- turers of truck seats offers air-cushion-ride seat features. Air- cushion-ride seats are known to absorb only about 20% of the whole-body vibration, so although those seats might feel more comfortable, they do not decrease whole-body vibra- tion influences all together. Thus, wellness programs such as Gettin’ in Gear need to stress to commercial drivers that they need to maintain a high level of physical fitness, manage and control their overall weight, select and adjust proper driver seating, and most of all take periodic breaks away from driving, during which they do some modest amount of exercises to break up the risk of MSDs attributable to back pain, or other CTDs such as carpal tunnel syndrome. A successful workplace ergonomics pro- gram can significantly reduce the number and types of mus- culoskeletal injuries (Grossman 2000; Tyler 2002, 2003). See also the TCRP Report 25 (You et al. 1997). 2.6.6 Psychological Stress and Mental Health Disorders Psychological stress. A dictionary definition of stress might include such things as “a mentally or emotionally dis- ruptive or disquieting influence causing distress.” According to Orris et al. (1997) this influence or stressor stimulates the sympathetic nervous system’s fight or flight response, neu- roendocrine secretion of corticosteroids, and consequent cardiovascular, hypertensive, gastrointestinal, and immune system impairments (see also Hancock and Desmond 2001). Stress-mediated immune system dysfunction may predispose individuals to arthritis, cancer, and autoimmune diseases. Many times a day, a person can experience stress-causing events that signal the body to produce numerous biochemical changes, mainly the hormones adrenaline and cortisol. A 1997 study examining psychological stress among 303 parcel deliv- ery drivers revealed these drivers scored significantly higher than the U.S. population on four common measures of job stress. This study (Orris et al. 1997) also noted these drivers had higher stress levels than 91% of the U.S. population on the best single scale of psychological stress (catecholamines). In another study among a paucity of such reports on commercial drivers, Evans and Carrere (1991) found a high degree of asso- ciation between exposure to peak traffic conditions and abnormal on-the-job levels of adrenal compounds in the urine of urban bus drivers. A NIOSH report, Stress at Work (1999), suggested that job stress can be defined as the harmful physical and emotional responses that occur when the requirements of the job do not match the capabilities, resources, or needs of the employee. The report says job stress poses a threat to employees’ health and in turn to the health of organizations. M. Mayer, a stress management expert states that stress levels in the workplace are getting worse as a result of poor management training and practices, feelings of a lack of control over the work environ- ment, and corporate cultures that value equipment over peo- ple (Mayer 2001). NIOSH indicates there is ample evidence some workplace stressors associated with overtime and extended work shifts may be correlated with various illnesses, injuries, and health behaviors. Overtime was associated with poorer perceived general health, increased injury rates, more illnesses, or increased mortality in 16 of 22 studies examined in a NIOSH review of work settings that included from health care work- ers, nuclear power plant operations, and electronics manu- facturing plants (Caruso et al. 2004). Four studies of extended work schedules reported the 9th to the 12th hours of work were associated with decreased alertness and increased fatigue, lower cognitive function, declines in vigilance, or increased injuries (Caruso et al.). Davis (2004) suggested that stress research shows that common tensions, whether the result of 50-hour work weeks, demanding supervisors, or personal concerns, can create a sense of unease or stress. Continuous high levels of stress can and do cause illness, poor judgment, nonproductive rela- tionships, and substandard performance. Experts in the stress management field point out that a given circumstance may be stressful to some people and not to others. That is, it is not the event that causes stress; rather it is the person’s reaction to the event that causes stress. Stress reactions vary, but they often include headaches, muscle tension, fatigue, insomnia, fuzzy thinking, and emotional, and other problems. Stress can increase the severity of already existing illnesses (Davis 2004; Tyler 2003; Goetzel 2005). Goetzel reviewed literature on the effects of stress in the workplace, both from an individual and an organizational 16

perspective. Goetzel indicated that when one couples indi- vidual health concerns with organizational stressors such as downsizing, lackluster senior management, poorly commu- nicated policies, and an environment without clear purpose, the potential for productivity losses can be pronounced. Personal stresses, along with job pressures and stresses may manifest as symptoms reflecting increased health, safety and productivity risks for the individual and the organization. Such symptoms may present themselves as medical condi- tions (e.g., chest and back pain, heart disease, gastrointestinal disorders, headaches, dizziness, weakness, repetitive motion injuries); psychological disorders (e.g., anxiety, aggression, irritability, apathy, boredom, depression, loneliness, fatigue, moodiness, insomnia); behavioral problems (e.g., accidents, drug and alcohol abuse, eating disorders, smoking); and organizational malaise (e.g., absence and tardiness, poor work relations, high turnover, low morale, job dissatisfaction, low productivity). In reporting on the costs of stress to the economy, Tyler (2003) and Davis (2004) quote figures from the American Institute of Stress (AIS), indicating that increasing costs of stress can be witnessed in the rapidly increasing cost of health care. In 2003, AIS estimated up to 90% of physician visits in the United States are probably stress related. The AIS quoted BLS statistics stating the median work absence attributable to stress was 23 days in 1997—more than four times the median absence for all occupational injuries and absences (Tyler 2003; Davis 2004). The AIS reported that stress costs U.S. businesses between $200 and $300 billion annually in lost productivity, increased workers’ compensation claims, turnover, and health care costs. Good Mental Health and Depression. The relationship between poor mental health and employers’ costs has been examined more recently (Goetzel). For example, a study by Goetzel et al. (1998) showed that employees who are depressed and highly stressed cost employers significantly more in health care costs compared with those without these psychosocial risk factors. Other studies documented the relationship between poor health and productivity losses (Simon et al., 2001). Clax- ton et al. (1999) demonstrated that when workers are appro- priately treated for depression, their absenteeism drops. The four most common mental health disorders are depression, bipolar disorder, generalized anxiety, and post- traumatic stress. Perhaps one of the least understood mental health disorders with its affects on job performance and health care costs is that of depression (Conti and Burton 1994). Davis reported the Society for Human Resource Man- agement (SHRM) estimated costs associated with depressive disorders are on the rise, and SHRM estimated depression costs employers from $30 to $40 billion each year (SHRM 1999). Although the costs of depression are high, the costs of untreated depression are much higher. When depression is not managed, employees may complain about a variety of physical problems. The SHRM report estimated up to 50% of all visits to primary care physicians are made because of conditions caused by or exacerbated by mental problems. The National Mental Health Association reported people with depression are four times more likely to suffer heart attacks than are those with no history of depression (Tyler 2002). Atkinson (2000) reported that employees who participated in a stress management program took fewer sick days than non-participating co-workers. Those who received stress management assistance saw doctors 34% less often than their fellow employees who did not get assistance. Atkinson concluded that a worksite program focusing on stress man- agement, along with education for small groups can reduce illness and the use of health care benefits. Teaching employees how to recognize stress reactions and the dangers and damag- ing effects of stress can be a powerful incentive for them to change their responses to the stress triggers in their lives. Tech- niques taught include deep-breathing exercises, guided imagery, and music therapy. Tyler (2003) reports that stress management programs have to be marketed so they show a link to the bottom line. Positioning stress management as a performance enhance- ment strategy and tracking results such as changes in productivity, absenteeism, turnover, and adverse incidents strengthens the credibility of stress management programs (Tyler 2003; Davis 2004). FMCSA 49 CFR 391.41 (b) (9) states that a person is qualified to drive a CMV if that person has no mental, nervous, organic, or functional disease or psychiatric disorder likely to interfere with his or her ability to drive a CMV safely. The reg- ulations go on to state that emotional or adjustment problems contribute directly to an individual’s level of memory, reason- ing, attention, and judgment. These problems often underlie physical disorders. A variety of functional disorders can cause drowsiness, dizziness, confusion, weakness, or paralysis that may lead to a lack of coordination, inattention, loss of func- tional control and susceptibility to crashes while driving. Phys- ical fatigue, headache, impaired coordination, recurring physical ailments, and chronic nagging pain may be present to such a degree that certification for commercial driving is inadvisable. FMCSA further states that somatic and psychoso- matic complaints should be thoroughly examined when deter- mining an individual’s overall fitness to drive. Disorders of a periodically incapacitating nature, even in the early stages of development, may warrant disqualification. (See the report on the Conference on Neurological Disorders and Commercial Drivers and the Conference on Psychiatric Disorders and Commercial Drivers http://www.fmcsa.dot.gov/rulesregs/ medreports.htm.) 17

In CTBSSP Synthesis 1, Knipling, Hickman and Bergoffen (2003) cited National Institute of Mental Health (NIMH) figures indicating about 22% of adult Americans suffer from a diagnosable mental disorder. Major disorders include depression, other mood disorders, and anxiety disorders such as panic disorder and obsessive-compulsive neurosis. In Knipling et al.’s survey work with the commercial truck and bus industry, these mental health problems were not per- ceived by carrier safety managers and other survey respon- dents to be as important as other topics in their safety management arena with commercial drivers. In research work related to the concerns over commercial drivers, Greiner et al. (1997) conducted 81 observational work analyses to measure stressors experienced by operators at the San Francisco Municipal Railway transit system. Greiner et al. defined stress factors as hindrances to task performance attrib- utable to poor work organization or technological design. Stressors included work barriers, defined as obstacles that cause extra work or unsafe behavior; time pressure; monoto- nous conditions; and time binding or control over timing. No other mental health related studies nor citable data specifically concerning the mental health of commercial driv- ers were located for inclusion in this section. Nevertheless, depression and other mental health adjustment disorders can be serious health threats and can have implications for high- way safety. The FMCSA-ATRI Gettin’ in Gear wellness program devotes a considerable amount of course material and class- room time to the topic of commercial driver stress and pro- vides numerous recommendations for stress avoidance and stress alleviation techniques and countermeasures, including provision of relaxation tapes, as part of the Gettin’ in Gear Four-R challenge geared toward Relaxing and Relating to others (Krueger and Brewster; Roberts and York). 2.6.7 Alcohol, Prescription Drugs, Over-the-Counter Medications, Other Chemicals Substance abuse is estimated to be the actual cause of approximately 120,000 deaths per year in the United States, with more 80% of them attributed to alcohol and around 20% attributed to other drug use. Alcohol and other drugs contribute to unintentional injury, suicide, and other violent deaths, and they are factors in a high percentage of chronic diseases (Healthy People 2000). According to the 2005 U.S. National Survey on Drug Use and Health’s National Find- ings, 19.7 million (8.1%) of the U.S. population used an illicit drug in the year 2005; 71.5 million (29.4%) used a tobacco product, and 126 million (51.8%) of Americans aged 22 and older used alcohol during the month prior to being surveyed (SAMHSA-OAS 2007). Safe-driving and the use of alcohol do not mix. For drivers who suffer from alcoholism, safe driving has become a huge public safety issue. For decades, annual U.S. DOT crash statistics reported alcohol was a factor in more than 40% of all traffic fatalities nationwide. The issues are of special con- cern to the commercial driver community. This is why the blood alcohol concentration (BAC) restrictions for commer- cial drivers are so much more strict for CMV operators (BAC 0.04) than for passenger car drivers (BAC < 0.08). So much has been written elsewhere about alcohol and driving, about driving performance under the influence of alcohol, and about the relationship of alcohol and the incidence of high- way crashes, that it is not focused on here. Alcohol use and commercial driving is an obvious safety issue and should also be viewed as a health and wellness issue. As for the incidence of alcohol and drug use by commer- cial drivers, Roberts and York summarized available reports as follows: • Crouch et al. (1993) studied the prevalence of drugs and alcohol in 168 fatally injured truck drivers and noted alco- hol was present in 12.5% of these drivers. Alcohol measures exceeded the legal limit of BAC 0.04% in 1% of these driv- ers. Marijuana was detected in 13%, cocaine was detected in 8%, and stimulants were detected in 11.3% of these cases. • In a Finnish study of 168 fatal-to-the-truck driver acci- dents from 1984–1989, Summal and Mikkola (1994) reported less than 1% of these drivers were found to be driving while intoxicated. • A 1986 study of 317 truck drivers randomly screened for drugs and alcohol in Tennessee revealed alcohol was pres- ent in less than 1% of these drivers; but 15% had evidence of marijuana, 2% had evidence of cocaine, and 15% had evidence of stimulants in their blood systems (Lund et al. 1988). • Korelitz et al. inquired almost 3,000 drivers attending a trucking trade show and determined 23% of all the drivers may have a drinking problem as indicated by their responses to questions regarding personal drinking perceptions. • An Australian study of 268 cited truck drivers revealed 15 to 18% of them had been convicted for driving while under the influence of drugs or alcohol (Hartley and Hassani 1994). • Crouch et al. reported a 1989 survey revealed 26% of drivers were perceived by their peers to be driving under the influence of drugs. Roberts and York expressed concerns over commercial drivers’ use of “heavy stimulants” because stimulants produce strong central nervous system stimulation and increasing physical and mental alertness. Citing the Physician’s Desk 18

Reference (1987), Roberts and York characterized amphet- amines as bringing about an elevation in blood pressure; however, the warnings include onset of increasing restlessness, dizziness, euphoria, and headaches as side effects, and state- ments that amphetamine use may impair the ability of a person to engage in potentially hazardous activities such as operating machinery or vehicles. Repeated use of amphet- amines can lead to drug dependence and can begin to cause irrational behavior, restlessness, anorexia, insomnia, agita- tion, tremors, increased motor activity, hallucinations, hostil- ity, and aggressive behavior (Pidetcha et al. 1995). FMCSA’s report to Congress on the Large Truck Crash Causation Study is an in-depth assessment of a nationally representative sample of large-truck fatal and injury crashes during 2001 to 2003 (FMCSA 2006). The report stated that among truck drivers, prescription drug use was an “associ- ated factor” in 28.7% of all crashes sampled, and over-the- counter drugs were an associated factor 19.4% of the time. FMCSA indicated an associated factor may not have con- tributed to a crash, but what was known is that the factors were present at the time of the crashes. Krueger et al. (2007) stated that at present, the commercial driving industry appears to have considerable control over illicit drug use in the employed work force. This is likely in part due to randomized urine testing of drivers for recreational and drugs of abuse and imposing harsh penalties such as loss of one’s job for positive test results; albeit some commercial driv- ers are still testing positive for such illicit drug use. Thus far, the only consensus agreement for allowable use of a stimulant by commercial drivers is that for consumption of caffeine and the many other stimulating substances similar to caffeine (e.g. guarana, taurine, etc.) found in energy booster products (drinks, food bars, chewing gum, etc.) commonly sold over- the-counter in health food stores, truck stops, and even grocery stores. Krueger et al. (2007) also reported that drivers sometimes take prescription or non-prescription medications, other chemical substances, and drugs (e.g. dietary pills, antihistamines, etc.): (1) as treatment for illnesses, or for relief from symptomatic ail- ments; (2) as self-administered countermeasures to fatigue (e.g. stimulants or hypnotics); or (3) for recreational purposes (e.g. alcohol, psychotropic substances). Some medications, or drugs, not only bring the driver relief from the discomfort and symptoms of various illnesses, or ailments, but such chemical substances also can have an impact on levels of driver alertness and therefore can affect driving performance and safety. Prescribed medications taken under a physician’s orders may treat some medical condition or ailment (e.g., drugs prescribed for hypertension, cholesterol control, heart conditions, depression, and other illnesses and conditions). Drivers may take a variety of prescriptions or over-the-counter non-prescription medications (e.g., sedating or non-sedating antihistamines, pain relievers) for treatment or relief from respiratory ailments like asthma, chronic bronchitis, emphy- sema, and seasonal allergies (e.g., hay fever, rhinitis; see Cockburn et al. 1999). Some drivers self-administer dietary supplements (weight loss or appetite suppressant pills); performance and mood enhancers, energy boosting drinks, pills, food bars, and other substances; stimulants (including caf- feine from various sources, and numerous other compounds that act in caffeine-like ways, e.g., guarana and taurine found in energy drinks); hypnotics (sleeping pills, melatonin); alcohol, and other chemical substances (Krueger et al. 2007). There is not enough scientific evidence on the performance effects of many such medications and the myriad of other chemical substances, either when administered singly, or in combination with others. The interactive and synergistic effects of many chemicals, medications, and drugs that drivers ingest are largely unknown. Some medications have side effects, and manufacturers are required to place caution warnings on the containers or on printed instructions inside drug packaging. Side effects for commercially available drugs are published in the Physicians’ Desk Reference; however, if the compound is not classified as a drug, but rather as a nutritional supplement (e.g., melatonin used as a sleep enhancer), then it is not governed by FDA good manufacturing practices and may not be written about in the Physician’s Desk Reference either. Any performance data and study results from pharmaceutical company research on such topics are not readily available because they are considered to be proprietary. Thus, the performance effects of many sub- stances, drugs, nutrients, and self-remedies, which drivers ingest are not so easily known (Krueger et al. 2007). This leads to concerns that not only does the driving community not have a good handle on the effects of mixing such chemicals in the body, but the physicians and health care providers who exam- ine, treat, or counsel commercial drivers also do not have com- mand of such information. 2.7 Medical Conditions, Functional Impairment, and Fitness to Drive While specific conditions such as diabetes, hypertension, and cardiovascular disease justifiably focus attention on medical fitness to drive, it is the impairment of key safe driving abilities that may result from these conditions that is of greatest concern. The aging of society, coupled with an increasing shortage of commercial vehicle drivers, defines an emerging priority: to develop a practical method of identify- ing impairments in the sensory, cognitive, and physical abilities that most strongly affect driving safety. Recent research indicates a relatively narrow array of specific visual, physical, and mental abilities that may provide the best crash 19

prediction. Such functional impairments are not specific to a medical condition (i.e., visual deficits can result from more than one disease). The research in this area has implications for opportunities to improve driver functional screening. A driver’s functional status is a more accurate measure of fitness to drive than medical diagnosis alone. A medical diagnosis is an important marker, but a disease may produce varying levels of impairment due to its particular manifesta- tion or stage of progression (i.e., diabetes and Alzheimer’s disease). Also, different diseases may result in comparable levels of functional impairment. This is reflected in reports from both the TRB and the Organisation for Economic Cooperation and Development (OECD) describing model licensing procedures that are based on functional assessment, rather than medical diagnosis, for the general driver popula- tion (TRB 2004; Aging and Transport 2001). Ensuring that requirements for commercial vehicle drivers reflect the latest evidence in this area is no less urgent. 2.7.1 Challenges Associated with Functional Requirements for CVOs Functional requirements for commercial operators are stated in 49 CFR Part 391, Subpart E-Physical Qualifications and Examinations. These pertain to vision [§391.41(b)(10)], hearing [§391.41(b)(11)], and certain aspects of limb and digit function [§391.41(b)(2)]. Supplementary “Medical Advisory Criteria” in this CFR provide physicians with addi- tional functional criteria for selected medical conditions. With this limited guidance, physicians are asked to certify that they have not detected “the presence of physical, mental, or organic conditions of such a character and extent as to affect the driver’s ability to operate a commercial motor vehicle safely,” nor any specific impairing conditions identified in the CFR (e.g., “has no current clinical diagnosis of alcoholism”). Only in selected areas are there well-defined requirements for a particular level of function for qualification to operate a commercial vehicle. Otherwise, the physician’s judgment determines when an impairment is severe enough to merit disqualification, when more extensive tests are needed, or when driver certification is restricted to a shorter period with a requirement to monitor and re-check. The AMA’s Council on Ethical and Judicial Affairs published recommendations addressing “physicians’ legal and ethical obligations with respect to reporting physical and men- tal conditions which may impair a patient’s ability to drive” (AMA 1999). The AMA underscored physicians’ traditional respect for the individual and desire to promote patient autonomy, while concurrently articulating the responsibility to recognize impairments in driving ability that pose a threat to public safety. Two criteria are paramount: (1) the physi- cian must be able to identify and document physical or mental impairments clearly related to driving ability and (2) the driver must pose a clear risk to public safety. 2.7.2 New Research Relative to Functional Abilities and Public Safety New research findings link indicators of public safety (crash risk) to objective levels of impairment in functional abilities. These findings can provide physicians with tools to satisfy legal and ethical responsibilities under the AMA, while meeting the intent of the federal regulations to certify a person is qualified to operate a commercial vehicle. The FMCSA establishment of an NRCME increases the impor- tance of disseminating this information. These examiners will apply a revised and standardized set of procedures in driver qualifications assessments. Recent research which focused on the cognitive abilities needed to drive safely appears to hold great promise. Decades of research on attention, perception, and cognition as related to crash occurrence led to a pilot test of an enhanced func- tional screening battery. This battery is aimed at enduring characteristics (sometimes referred to as “traits”) that is, the necessary focus of a screening instrument for driver licensure rather than transient performance-impairing factors, like fatigue, that may easily be remediated. The study was spon- sored by the National Highway Traffic Safety Administration (NHTSA 2005) and the National Institutes of Health/ National Institute on Aging (NIH/NIA) with cooperation of the Maryland Motor Vehicle Administration (Staplin et al. 2003). Full documentation of the pilot test is posted in the Model Driver Screening and Evaluation Program on the NHTSA website. This study demonstrated significant increases in the risk of at-fault crashes, based on police reports, with measured declines in four cognitive abilities. The study included a rep- resentative sample of nearly 2,000 drivers age 55 and older who were tracked over a prospective interval averaging 20 months per driver. Because cognitive decline is more likely among seniors, older drivers were of special interest in this study, but age was not an analysis variable (crash predictor). The loss of function, not age per se, was tied to increased risk of causing a crash. In this research, the strength of the relationships between functional status and crash causation was measured via odds ratio (OR) analyses. This method contrasts the odds of at- fault crash involvement with a measured decline in cognitive ability against the odds of crash involvement without such a decline. An OR value of 1.0 indicates a functional measure has no predictive value in screening at-risk drivers, while increasingly higher OR values denote more potent predictors. The cognitive abilities identified as significant predictors of at-fault crashes in the NHTSA study and associated OR values 20

are shown in Table 1. Measurement tools used to assess each cognitive ability are also indicated in this table. As is depicted in Table 1, four functional abilities have a significant impact on the odds of a future at-fault crash. Visu- alizing missing information enables drivers to perceive a whole object when only part can be discerned. This facilitates early recognition of emerging safety threats and anticipation of hazards. Drivers with this functional impairment were at nearly five times greater risk of causing a crash than drivers without it (see Table 1). Visual search is an important ability for rapidly scanning the roadway environment for traffic control information, navigational information, and potential conflicts with other vehicles, particularly in the vicinity of intersections. A visual search impairment resulted in a 3.5 times greater risk of caus- ing a crash (see Table 1). Working memory is a cognitive ability that enables drivers to remember and apply traffic regulations, route-following directions, delivery instructions, and other task-dependent information while simultaneously attending to current traf- fic and roadway conditions. Drivers with this functional impairment were at nearly three times greater risk of causing a crash than drivers without it (Table 1). The contribution of visual information processing speed to safe operations is demonstrated by an ability to detect threats at the edge of the “useful field of view” while maintaining concentra- tion on what is happening directly ahead. Drivers with visual information processing speed impairments were at roughly 2.5 times greater risk of causing a crash than other drivers (Table 1). This study focused on passenger vehicle drivers; however, the reported relationships between functional status and crash causation are not vehicle or situation specific. The cog- nitive abilities cited define performance domains with near- universal applicability in driving experience (including commercial). The same impairments should be cause for greater concern among commercial vehicle drivers. The larger sizes, heavier weights, and longer braking distances that define commercial vehicles increase task demands on com- mercial vehicle drivers relative to passenger vehicle drivers, while room for driver error is reduced because of the greater consequences of a crash. Also, at this time, there are no proven options for cognitive retraining or remediation of the deficits highlighted in the NHTSA/NIH/NIA research. The measurement tools employed in the pilot study included a combination of manual and computer-based tech- niques. To improve the reliability and standardization of the functional measures, while reducing cost and improving the efficiency of administration, currently computer-based tests are used for all of these cognitive screens. Clearly, this would also facilitate continuing this research or pilot implementa- tions of cognitive screening programs with motor carriers. 2.7.3 Additional Functional Criteria for CVO Qualifications The status of research findings related to other functional criteria for commercial driver qualification deserves re-exam- ination. In the area of vision, prior research has pointed to the need for clarification and expansion of the visual field require- ment. A FHWA study concluded the vision standard should be amended to require at least 120 degrees of visual field in each eye, measured separately in the horizontal meridian (Decina et al. 1991). This recommendation was strongly supported in a subsequent review conducted by Berson et al. 1998. Other research on vision—specifically, contrast sensitivity (CS)—and crash involvement also deserves mention. Whereas, acuity measures an individual’s ability to resolve fine detail (high spatial frequency information) that contrasts sharply with its background, CS measures the ability to dis- criminate objects with edges that may be poorly defined and that have low contrast with their background. Roadway debris encountered at twilight or a curb or median barrier without painted delineation, a pedestrian in dark clothing, are all examples of important low contrast targets. The poten- tial for safety gains from screening for contrast sensitivity in addition to standard acuity measurement has been demon- strated in analyses dating to at least the early 1990s (Decina et al.), and state DMVs (e.g., California) have begun to intro- duce CS in their passenger vehicle licensing operations on a pilot basis. However, research has not yet established a stan- dard of performance for CS for CVO qualifications. Hearing requirements for commercial operators were addressed in a case-control study of commercial drivers with hearing disorders (Songer et al. 1993) and in a human fac- tors study to evaluate the FHWA hearing requirement (Robinson et al.). As summarized in an FHWA Technical Brief (FHWA-OMC 1999), hearing is required to detect both intentional signals and incidental sounds to safely operate 21 Table 1. Peak valid odds ratios for significant at-fault crash predictors. Functional (cognitive) ability: Odds Measurement tool Visualizing missing information (visual closure): 4.96 Motor free visual perception test, visual closure subtest Visual search (with divided attention): 3.50 Trail-making test, Part B Working memory: 2.92 Cued and delayed recall (auditory) Visual information processing speed (with divided attention): 2.48 UFOV® subtest 2 Ratio

a commercial vehicle. In efforts to update current standards it is likely that the “forced-whisper” test methodology should be phased out of use, testing of commercial drivers should probably be done at a wider range of frequencies than are currently prescribed (up to 4,000 Hz), and the use of pure- tone audiometry to objectively assess hearing ability should be expanded. Where research has provided clear evidence to establish standards of vision and hearing performance for CVO quali- fications and associated measurement techniques, there is still a requirement to bring practice in line with these research findings. Initiating practical methods for driver screening for impairments in cognitive abilities that have been validated as predictors of at-fault crashes should yield further benefits for industry and for highway safety. Research should continue to provide the best possible information to those charged with updating the physical, medical, and fitness standards for commercial driving qualifications, so as to be able to address not only transient states, diseases, and medical conditions, but also the specific functional abilities research has linked to crash causation. 2.8 Corporate Employee Health and Wellness Programs 2.8.1 Why Corporate Health and Wellness Programs? Corporate America has experimented with employee health and wellness programs for more than a quarter of a century. The motivations for such programs include management’s humanitarian concern for the general well- being of employees and maintaining an aura of corporate excellence. More practical goals include stemming rising insurance premiums, health care costs, and workers’ com- pensation; decreasing incidents of injuries, deaths, costly accidents, and absenteeism; finding replacement employees while some workers are out; and ultimately improving bot- tom line profits for the company. In both the for-profit and non-profit (e.g., government employers) businesses, now more than ever before, corporate America seems to be embracing company-sponsored employee health and well- ness programs, primarily to slow down the ever-escalating medical care costs provided by employers. Improved recruit- ment, increased productivity, and improved morale are among other wellness program benefits. Over the past several decades, literally thousands of com- panies in the United States and western Europe initiated health and wellness programs, with varied degrees of success. However, many companies that implemented health and wellness programs also demonstrated vacillating levels of sustainment of such programs. Many of the programs dissipated back to “doing business as usual.” In preparing this synthesis, the research team identified a limited number of commercial trucking and bus/motorcoach companies with company sponsored health and wellness programs. It is one of the intentions of this synthesis to provide useful informa- tion and recommendations to assist the commercial shipping and passenger transportation industries with information for practical decision making regarding whether to proceed with their own health and wellness programs in hopes of improv- ing the lives of employees (commercial drivers) and impact- ing highway safety in a positive way. 2.8.2 What Constitutes a Corporate Health and Wellness Program? Several different “models” of corporate health and wellness programs might be described. The essential differ- ences among them are largely more a matter of degree of emphasis rather than differences in actual inclusiveness of the various elements of any good employee wellness program. This synthesis first reports some experiences gleaned from the literature on corporate experiences with different types of programs and highlights various elements of company wellness programs. It outlines a few select models of what a prospective wellness program might look like for the trucking and bus/motorcoach industries. For an extensive treatise of the cost-benefit analysis and organiza- tional strategies of health management programs, consult the University of Michigan Health Management Research Center’s Cost Benefit Analysis and Report–2006 (Edington 2006) and the work of Ron Goetzel for several decades of corporate wellness research that led to the current focus on Integrated Occupational Health, Safety and Health Promo- tion Programs in the Workplace (Goetzel 2005). Many pertinent peer-reviewed journal articles done by the staff at the University of Michigan’s Health Management Research Center describing work related to the topics of this synthesis are listed in the supplemental bibliography. There are numerous publications available in the health and wellness “industry or trade” on what to include and how to conduct workplace wellness programs. They are far too numerous to describe or even quote from them in this syn- thesis. For readers motivated to pursue this topic further, one publication which may be particularly pertinent and helpful is “Building Blocks for a Successful Workplace Wellness Program” (Huber et al. 2005). This volume serves as a primer for either wellness managers who are new to the field or for experienced managers who want a guidebook. It identifies numerous practical steps to take in beginning a program and explores elements, strategies, characteristics, and objectives employed in successful wellness programs. The compilation of sound advice, great ideas, proven methods, practical goals, 22

and “how-to” tips was produced by the editorial team from Wellness Program Management Advisor, a popular monthly news briefing for workplace wellness professionals. 2.8.3 Transportation Industry Employee Wellness Programs Roberts and York compiled a list of wellness programs in the trucking industry. A number of them are briefly described as follows: Ruan Transportation Management Systems. Holmes et al. and Roberts and York described the program of Ruan Transportation Management Systems, located in Des Moines, Iowa. In 1995, Ruan had more than 3,000 employ- ees to provide commercial vehicle and employee leasing services for private and for-hire trucking operations in 38 states. Ruan designed a wellness program for their com- mercial truck drivers as part of a management initiative to control rising health care costs. The company’s health care claims experience showed heart problems were the largest cost category for 2 of 3 observed years, and costs associated with heart disease represented more than 10% of total health care costs. In consultation with wellness specialists, Ruan first identi- fied the principal factors contributing to their employees’ heart problems: elevated blood cholesterol, elevated blood pressure, overweight employees, lack of exercise, and smok- ing. Since the first three of those risk factors are affected by nutrition, they sampled 300 drivers to determine their health and nutrition habits, by asking questions regarding meal and snack frequency and food selection choices while on the road. This survey revealed dinner as the most frequent meal eaten, and burgers and steaks as the most common meal of choice. Additionally, 48% of the drivers indicated snacking while on- the-road with potato chips as the most frequent snack choice. With the assistance of a nutritionist, the company’s man- agement team designed a nutrition intervention program and compared effectiveness of this program using a test and a control group of drivers to determine if a wellness program emphasizing driver nutrition could significantly affect the risk factors attributable to heart problems (Holmes et al.; Roberts and York). The program consisted of nutrition and wellness counseling, printed information designed to educate drivers about healthy meal choices, and “healthy snack bags” containing such items as fresh fruit, juices, raisins, pretzels, and fig cookies. The nutrition intervention program achieved significant differences among the test and the control group of drivers in areas of weight reduction, improved fitness level, and smoking cessation. The team also witnessed improve- ments in blood cholesterol levels, body fat, and blood glucose levels. Follow-up interviews with the drivers also noted improved feelings about the company (Holmes et al.). Roberts and York used telephone interviews of 23 trucking companies to elicit health and wellness program information (circa 1998–99). Only six trucking firms had or were willing to highlight their wellness programs. Roberts and York iden- tified these companies only by number in their report for FMCSA. The difficulties of establishing a wellness program in the commercial driver community are portrayed in the report and summarized here. Motor Carrier #1 was a truckload carrier in the United States with more than 14,000 drivers and 2,500 corporate staff members based in 15 operations centers around the United States. The company has a wellness program because of upper management interest and support. The corporate wellness coordinator indicated that cardiovascular claims were the number one medical cost for truck drivers, and that the company was implementing a disease management program, although specifics had yet to be determined. Other elements of the health and wellness program included a $30 reim- bursement for smoking cessation, an employee health assess- ment program, and stress management and aerobics classes. The wellness coordinator noted the program weakness was not reaching drivers or having wellness program representa- tives at local operations centers. The most extensive employee program participation was found at the corporate office where the wellness program was administered. Seventy-five percent of the operations centers were equipped with fitness rooms and employee cafeterias. Roberts (a dietician) reported that during her visit to one of these operations centers, there was no evidence of usage of the fitness room even though about 800 drivers passed through the facility each day. The majority of cafeteria food choices were typical high-fat menu choices such as bacon and eggs and hamburgers and cheeseburgers. Deli sandwiches and prepackaged salads were also available. At the time of Roberts’ visit (1999), the facility did not have a local wellness coordinator. Motor Carrier #2 was a for-hire flatbed operation with approximately 800 trucks. The company began a wellness program to keep health care costs down. However, Roberts and York observed the wellness coordinator had little under- standing of the company’s health care costs and had not ana- lyzed any data other than to know that costs were increasing. The wellness program reached primarily the office staff and not the drivers. It was estimated that more than $100 was spent on wellness per office staff employee, while almost nothing was spent on drivers. The company had a large fit- ness facility, cafeteria, and a motel at the corporate head- quarters. Lunch seminars, health assessments, and a newsletter were provided. It appeared there was little partic- ipation by drivers in the company wellness program. Weak- nesses were inability to reach drivers, newness of the wellness program, and lack of personnel to administer the program. 23

Motor Carrier #3 was a refrigerated carrier, with a large national operation and with 2,100 drivers and a staff of 300 operations and support staff personnel. Driver turnover rates reportedly exceeded 200%. The company was interested in wellness programs because the recently appointed president believed that health affects every part of the business. The company provided a $200 wellness benefit for all employees and distributed a health-oriented newsletter. However, at the time of the interviews, the company had not figured out how to effectively reach drivers with the wellness program. Motor Carrier #4 was a refrigerated carrier operating in all 50 states with an irregular route truckload operation. The company had 2,000 independent owner-operators and 400 in- house corporate staff support personnel. They too were in the beginning stages of developing a wellness program and at the time provided limited amounts of health information through a company newsletter. Flu shots, health screening, and fitness membership reimbursements were available to all employees and operators. The company was building a fitness center at the corporate headquarters. As with other trucking compa- nies, reaching the drivers was its biggest concern. This was reflected in participation rates—nearly 20% of corporate staff and only 1% of drivers participated in the company wellness program. Motor Carrier #5 was a private fleet operation consisting of 500 over-the-road refrigerated trucks. Four years previously, the company implemented a fatigue/health education pro- gram designed for its truck drivers. The program included classroom instruction on fatigue and other health issues and provided a manual containing information on exercise, diet, stress, and fatigue. The program demonstrated very positive results with a 40% reduction in accidents and large program acceptance by the drivers (Harrington 1995). As often hap- pens, the individual who developed, implemented, and championed the program left the company for a position elsewhere and, since the departure, the corporation reorgan- ized the fleet safety function, placing it under control of risk management, where the level of support by the company was far less. All program activities at the time of the interview were placed on hold. Motor Carrier #6 was a Western-based trucking company with approximately 3,000 truck drivers and 300 to 500 cor- porate employees. It attributed the more than 90% turnover rate primarily to the length of time truckers are away from their families. The company was building a new facility for their drivers to include sleeping quarters, a cafeteria, a the- ater, and a fitness center. In a desire to keep health care costs down, the company was giving high priority to employee health. The wellness program was initiated as a benefit for the employees. The program offered health fairs, weight management programs, exercise incentive programs, and lunch and learn sessions which brought in outside profession- als to speak on subjects such as diabetes, healthy food choices, and starting a fitness program. Other activities offered were golf, basketball, volleyball, and aerobics. A bulletin board with tips and facts on improving health was maintained. Truck drivers were told of the wellness programs during their orientation and were given a manual with information about stress management, healthy eating, and exercise tips. Nutri- tion packets were made available for drivers and included facts on healthy snacking and calories. The program’s participation rate averaged 20 to 25% of office employees and 10% of drivers. The coordinator did not think they had enough resources to reach more of the drivers. Roberts and York also described elements of an additional non-trucking company wellness program as follows: Grocery Retail Company is an employee-owned Midwest- ern grocery retail company with 35,000 employees, includ- ing 175 truck drivers. The company is decentralized with 250 locations in 7 states. The company placed much emphasis on employee health and started its own wellness program as a benefit for employees. It made the program available to all employees, their spouses, and retirees. Program activities which varied from location to location, often included seminars, recreational activities, and yearly health risk assessments-which were quite popular because they included medical testing of blood cholesterol, blood sugar, blood pressure, body fat, and fitness levels. After testing, a coun- selor explained the results and gave the employees or family members information and recommendations on how to improve their overall health. Follow-up contacts were made with high-risk employees to help in the behavior change process. The corporate office had “lunch and learns” cover- ing topics from osteoporosis and arthritis to healthy eating and safety issues. Every employee was provided a monthly health newsletter published by the company. The wellness program was staffed with a wellness coordinator, a consult- ant as needed, and five consultants for the health assessments and follow-ups. More than 75% of their full-time and regular-time employees participated in the health risk assess- ments, and participation in the overall wellness program was quite high. The company, which is self-insured, experienced a reduction in health care costs; employees also realized health care savings. Seven years passed with no increase in premiums and in 2 of the previous 10 years employees received a health insurance premium rebate. 2.8.4 Overall Benefits of Employee Health and Wellness Programs Davis said that the rising costs of health care today mirror those of the late 1980s and early 1990s, before managed care clamped down on health costs for a short time. In 2002, an HR consultancy firm estimated large employer (>100 employees) 24

costs at $4,026 per employee per year—three-fourths of the cost of premiums. Employees were estimated to pay an aver- age of $1,401 more in costs in 2002 than in 2001 (SHRM 2002). Gale (2002), a workplace health promotion specialist cited by Davis, estimated that, at most companies, 10% of all employees consume 80% of the health care costs. These are individuals at highest risk for conditions such as diabetes, high cholesterol, and heart disease, and they are the least likely employees to change unhealthful behaviors. Gale suggested the primary goal of any employee wellness program should be to return the highest risk people to low-risk status while help- ing the other 90% maintain a low health-risk lifestyle. How- ever, Gale noted that getting the 10% of high-risk employees to participate in managing their health and well-being can be a particularly challenging task. With these principles in mind, the staff at the University of Michigan Health Management Research Center points out that while high-risk individuals are often the targets of most health intervention programs, low-risk individuals often are allowed to live their lives with little or no apparent attention; and eventually they become susceptible to increas- ing risks without the proper attention to help them maintain their low-risk status. The premise of the Health Management Research Center therefore is to reduce the flow of low- or medium-risk individuals to high-risk which will result in reduction of the total of high-risk individuals within a few years. The important metric and the gold standard for suc- cess is the percentage of the population at low-risk (Edington). The Wellness Council of America (WELCOA), a nonprofit health promotion organization, is a leading provider of what it claims is a unique workplace wellness model—improving employee health and safety through deployment of its wellness coaches directly to the workplace. One of the goals is to empower employees and to get them to participate at significant levels in their company’s wellness programs and thereby achieve outstanding improvements in employee health. Some of WELCOA’s programs are outlined on its well- ness coaches website at http://www.wellnesscoachesusa.com. WELCOA suggests that although an employer cannot force employees to participate in a health and wellness pro- gram, the employer can tie such participation to an employee’s being able to participate in the employee benefits package. WELCOA estimated the typical benefits package costs a company expends is about $4,000 per employee, per year. Considering that outlay of expenditures, WELCOA believes a company has the right to ask individuals to, at a minimum, participate in a series of commonly provided health screenings or health risk appraisals. In addition, the company can implement targeted wellness programs, which are more likely to be used because people are more aware of their medical and health conditions following these screenings or appraisals (University of Michigan Health Management Research Center 1997 and 2006). Goetzel et al. (1998) followed approximately 46,000 employees from more than six large health care purchasers for 3 years after the employees had completed a health risk appraisal. Employees at high risk for poor health outcomes had significantly higher expenditures than did employees at lower risk in seven of ten risk categories: those who reported them- selves as depressed (70% higher expenditures), at high stress (46%), with high blood glucose levels (35%), at extremely high or low body weight (21%), former (20%) and current (14%) tobacco users, with high blood pressure (12%), and with sedentary lifestyle (10%). These same risk factors were found to be associated with a higher likelihood of having extremely high (outlier) expenditures. Employees with multiple risk pro- files for specific disease outcomes had higher expenditures than did those without these profiles for the following diseases: heart disease (228% higher expenditures), psychosocial problems (147%), and stroke (85%). The authors concluded common modifiable health risks are associated with short-term increases in the likelihood of incurring health expenditures and in the magnitude of those expenditures. A University of Michigan Health Management Research Center survey (1997 and 2006) of 1,035 major employers found that 85% of responding employers offer some form of health promotion, and 75% use health risk assessments. Incentives for employees making healthful lifestyle changes and the penalties for those engaging in high-risk behaviors, such as smoking, are becoming more prevalent. Health Management Research Center pointed out that a variety of factors associated with unhealthy employees can contribute to corporate costs including: absenteeism, medical expenses, distress to other employees during absences, and cost of replacement personnel. Davis concluded health promotion is typically approached in two ways: (1) decreasing external risks, such as by elimi- nating carcinogens and providing adequate on-the-job safety measures and (2) reversing risk behaviors, such as smoking and physical inactivity. The University of Michigan Health Management Research Center (1997) reported that DuPont found absenteeism 10% to 32% higher among its employees who had any of seven health risks: smoking, obesity, high cholesterol, high blood pressure, excessive alcohol use, lack of exercise, and not using seat belts. After implementing a well- ness program at 41 of its sites, DuPont had a 14% decrease in absenteeism. Davis also reported that the Health Manage- ment Research Center looked at the Union Pacific Railroad’s health promotion program, which was instituted when the company determined its medical costs per employee were almost twice the national average. After implementing a med- ical self-care program, Union Pacific experienced a savings of $1.26 million annually. 25

Davis reported the Daimler Chrysler/UAW wellness pro- gram realized a savings of $4.2 million among bargaining union employees who participated from 1999 to 2001. The program, piloted in 1985, had approximately 44,000 employ- ees participate from 1985 to 2004. Daimler Chrysler had more than 32,000 active participants in 2001. Daimler Chrysler contracts with health and fitness businesses to administer their wellness program, which is voluntary and confidential (Daimler Chrysler/UAW 2001). Their program activities are aimed at four goals: • Empower employees to be wise health care consumers and improve their health • Keep low-risk employees in the low-risk category • Target high-risk employees with focused interventions • Provide cost-effective wellness activities designed to con- tain health costs The Daimler Chrysler program employs the following incentives and techniques to increase and maintain employ- ees’ participation in the program: • Gifts distributed at health screenings • Well-bucks “money” earned for participating in activities that can be redeemed for prizes such as gym bags, sweat- pants, first aid kits, and polo shirts • Targeted marketing based on prior participation • Incentives for participating employees who bring in new participants • Convenient access to health screenings in the worksite • Interactive, fun, and non-threatening activities A study done of Johnson & Johnson’s large-scale wellness programs demonstrated positive long-term financial and health effects (Breslow et al. 1994; Davis 2004). The Johnson & Johnson study reviewed medical claims for more than 18,000 domestic wellness program participants from 1995 to 1999. Medical expenditures were evaluated for up to 5 years before and 4 years after the wellness program began. As a result of linking the program to health care benefits and finan- cial incentives, the company saw participation rise from 26% in 1995 to 90% during the study period. Financial incentives included a $500 medical plan discount for employees who completed a health risk assessment and, if recommended, enrolled in a high-risk intervention program. Employees par- ticipating in wellness activities had significantly lower medical costs and achieved improvements in several health risk factor reductions in 6 of 13 risk categories in the first year of the program: sedentary lifestyle, hypertension, high cholesterol, low dietary fiber intake, poor motor vehicle safety practices, and tobacco use/smoking. In the first 4 years of the program, Johnson & Johnson averaged $8.5 million savings annually. Savings came primarily from lower administrative and health care use costs (Johnson & Johnson 2002). In a brief examination of health and wellness programs in other segments of the transportation industry, TCRP Report 77 (McGlothin Davis, Inc., 2002) reported four health and wellness programs in the transit industry. • The Utah Transit Authority (UTA) in Salt Lake City, Utah. Since 1990, UTA has had a quality-of-life program called the Healthy UTA. Activities included sports programs, health evaluations for all employees and their spouses, a fitness facility at each worksite, health education, and discount tickets to recreational events in the community. In 2000, more than 1,000 employees participated in one or more of the wellness activities. • Metropolitan Area Rapid Transit Authority in Atlanta, Georgia. The program includes a twice per year health fair, monthly massages, brown-bag health education classes, monthly health promotion newsletters, and fitness facilities at each location. • Regional Transportation District in Denver, Colorado. The program, Champions of Transit, integrates community involvement, employee wellness and employee recognition activities, communicating its commitment to being a pos- itive force in the community and to its employee health, well-being, and development. • Pierce Transit in Tacoma, Washington. Health Express is an employee-committee program which sponsors health education and support to help employees make healthful lifestyle choices. 2.8.5 Other Findings of Interest Morris et al. (1999) pointed out that blue-collar workers are less likely to participate in worksite health promotion programs than are white-collar workers. Workers in a manufacturing setting, who engaged in welding, assembly, machine operation, maintenance, and painting, viewed the worksite health climate less positively than did white-collar workers. White-collar workers perceived more flexibility to exercise, a more healthful norm for nutrition, and more support from supervisors and co-workers for healthful behavior. Blue-collar workers had a higher norm on only one health behavior, that of an antismoking sentiment which was higher than that of the white-collar workers. Davis reported employers are increasingly implementing disease management (DM) programs as part of a health and wellness strategy to address the rising costs of treatment associated with chronic health conditions. Employers embrace DM as a way to improve the health of their employ- ees, boost productivity, and reduce medical insurance premiums. According to the Pharmacy Benefit Management 26

Institute, in 2001, 44% of employers offered DM for chronic medical conditions, up from 14% in 1995 (Atkinson 2001, 2002). Asthma, diabetes, and cardiovascular disease are the three major illnesses most commonly addressed by DM programs. The goal of DM is to ensure employees receive the best care possible and avoid complications. DM involves employees in their care, ensures proper treatment by physicians, and helps make sense of medical information. Often a contracted service, many DM programs focus not only on cutting health care costs, but also on improving employee attendance and ability to contribute at work. DM programs encourage employees to sign up with a health care provider who educates them about their diseases—how to manage them and the importance of proper medical care. DM programs hold down costs by providing employees and their caregivers with information on how to monitor and treat conditions and coordinate communication among the various stake- holders in the employee’s health care coverage (Atkinson 2001, 2002). Self-care and education efforts that focus on helping employees understand their illnesses and treatment are important aspects of DM programs. DM programs are some- times separated into three categories of service: (a) high-risk individuals who receive frequent telephone calls, as well as home visits or medical monitoring, (b) medium-risk indi- viduals who require frequent telephone contact, and (c) low- risk individuals who can get by with frequent mailings and occasional telephone contact (Atkinson 2002). Alan Pierce, a workers’ compensation attorney, prepared a top 10 list of reasons injured workers retain attorneys (Pierce 2002). The list is instructive in that it points the direction for employers to design portions of their employee wellness pro- grams in such a way that employers attend properly to the perceptions/expectations of their employees. They include 1. Workers’ compensation claim was denied. 2. There was no contact by the employer or the insurer with the injured employee. 3. There was overbearing or intrusive contact by the employer. 4. Bills went unpaid, prescriptions were un-reimbursed, or the check was late. 5. Lawyer advertising and solicitation caught the injured worker’s attention. 6. The advice of friends, family, or medical provider swayed the worker. 7. There was a lack of a modified-duty plan or harassment upon return to work. 8. Employee was dissatisfied. 9. Employee had loss of health insurance or other benefits. 10. The accident or injury should never have happened. 2.8.6 Does Workplace Drug Testing Reduce Employee Drug Use? Weed out Undesirables? In September 2006, the Substance Abuse and Mental Health Services Administration released its National Survey on Drug Use and Health (SAMHSA-OAS). Employers screen their workers and job applicants for drug use with the expectation that such testing will deter worker drug use. It is a cause-and-effect relationship that many employers rely on, and a belief that fuels a multibillion-dollar drug testing industry. When researchers at the University of California, Irvine (UCI), examined alternative explanations to test the link between employee drug testing and lower rates of employee substance abuse, the results did not definitively prove drug testing directly reduced drug use, but those results were the strongest evidence to date (Chris Carpenter of UCI, quoted in Occupational Health and Safety, Septem- ber 27, 2006; Carpenter 2007). According to the UCI study, other workplace drug policies, like a written “zero toler- ance” standard or employee assistance programs, do not explain away the association between testing and less worker drug use. The UCI study also considered the health profile of employees at worksites with lower drug-use rates to deter- mine if healthier workers self-select workplaces that are more likely to screen their employees. Because other policies and workforce characteristics likely dampen drug use to some degree, and because previous research did not account for those effects, Chris Carpenter said that past studies may have overstated the testing-drug use link. Carpenter said that fail- ing to account for other workplace characteristics and drug policies may bloat the testing-drug use association by as much as 25%. The researchers said that could be valuable information to budget-conscious personnel managers who are weighing the costs and benefits of establishing a drug- testing program. When the UCI study compiled data on marijuana screening at private, for-profit companies across the country, results mirrored previous studies, again indicat- ing marijuana is the drug appearing most often in employee failed drug tests. The implications of such research and commentary by the UCI researchers to the commercial transportation industry are not clear; however, the trucking and bus/motorcoach segments of industry impose no-tolerance and randomized testing for drugs in employees. 2.8.7 Criteria for Successful Employee Health and Wellness Programs For the FMCSA, Roberts and York surveyed numerous tenets of successful wellness programs (e.g., O’Donnel 1997; 27

Association for Fitness in Business 1992) and from them, extracted, adapted, and outlined the following fundamental elements for a successful company-sponsored employee health and wellness program: Fundamental Health and Wellness Program Elements • Commitment from senior management is important (highest level, CEO if possible) – Monetary and personnel support – Philosophical support – Participation in the programs • Clear statement of philosophy, purpose, and goals • Needs Assessment: survey the employee base, check health care costs • Strong program leadership • Use of effective and qualified professionals (e.g., wellness consultants) • Accurate, up-to-date, research-based information made available to participants • Effective communication – High visibility – Successful marketing – Motivating to employees • Accessible and convenient for employees (how to attract drivers) • Realistic budget • Fun, motivating, and challenging program philosophy • Supportive work/cultural environment – Company policies – Company attitude toward employee • Supportive physical environment – Cafeteria and vending provide healthy food choice options – Available fitness facilities – Windows, lighting, truck cab • Individualized to meet the needs of each employee • Defined evaluation system, establish criteria for success, changes • Shows results for the individual employees and the company Roberts and York provide extensive elaboration and expla- nation of most of these program elements, and readers are referred to those descriptions in the overall report by Roberts and York. That report can be found on the FMCSA website at www.fmcsa.dot.gov (publications). Many of the principles of the Roberts and York program development are embedded in the Gettin’ in Gear wellness program, and they appear in detail in the instructors’ manual and in the other train-the- trainer course materials distributed to course attendees (see Krueger and Brewster). 2.8.8 The New Paradigm: Integrated Occupational Health and Safety and Health Promotion Programs in the Workplace Goetzel (2005) describes a relatively new and emerging business strategy called Health and Productivity Manage- ment (HPM) aimed at improving the total value of human resource investments. Goetzel says HPM has been in the fore- front of advocating for integrated employee health, safety, and productivity management programs. These programs rely on the joint management of human resources benefits and programs that employees may access when they are sick, injured, or balancing work/life issues. They include health insurance, disability and workers’ compensation, employee assistance, paid sick leave, and occupational safety programs. Also included are activities meant to enhance morale, reduce turnover, and increase on-the-job productivity. Over the past 10 years, an integrated health, safety, and productivity model evolved. In part, businesses pursue an inte- grated approach as a business imperative because health benefits to employees have become increasingly worrisome. During 2000 to 2004, annual health insurance costs increased an average of 10 to 12% per year, and generally, additional increases are anticipated (Goetzel 2005). In 2003, the annual cost of providing health insurance benefits averaged $3,391 for employee-only coverage and $9,075 for family coverage. On average, employers paid 84% of the premium for employee-only coverage and 73% for family coverage (Gable 2003). However, Goetzel says when factoring in productivity related expenses, the costs to employers are significantly greater. Parry et al. (2004) estimated the overall health and productivity cost burden to employers averaged $16,091 in 2002. This included direct payments for health benefits and indirect payments attributable to lost productivity. Some expenses associated with lost productivity included hiring replacement workers when an employee is absent (absen- teeism) and reduction in services, loss of output and missed sales opportunities when employees are distracted or less attentive (e.g., an employee is at work but concerned about illness, etc.), especially when affected by poor health (presen- teeism). Workers in poor health, and those with behavioral risk factors, may cost the organization more than can be measured by adding up medical expenses; the spillover effects on other areas such as safety, morale, and productivity may be significant (Goetzel 2005). Goetzel et al. (2002) say that in many businesses, health, safety, and productivity issues are addressed separately, and discreetly, by different functions and departments in an organization: employee benefits, employee assistance, risk management, occupational medicine, safety, organizational development, operations, human resources, employee 28

relations, and labor relations. Fragmented, department-spe- cific strategies attempt to manage individual and organiza- tional risks although oftentimes these risks are common to several functions simultaneously within the organization and might be better managed through cooperative or integrated activities. Thus, HPM programs advocate an integrated health, safety, and productivity management model which establishes a new paradigm for working across departments to form a coordinated, synergistic, and unidirectional set of solution packages for both the employee and the company. This new paradigm forces managers to concentrate their efforts on improving the health and well-being of employees as a whole, not as individual cases, regardless of where the organizational benefit programs reside (Goetzel et al. 2003). This new and forward-looking approach to health and well- ness integrated across the organization is not easy and neces- sitates much organizational change, and hard work. (Consult Goetzel 2003 for details, especially his outline of the top 10 lessons learned in Health and Productivity Management (HPM) and Best Practices, pp. 34-39 and see Chapters 1, 5, and 10 in American College of Sports Medicine’s Designing Health Promotion Programs [Cox 2003]). 2.8.9 Commercial Driver Health, Wellness, and Fitness Training Programs A number of training programs have recently become available for encouraging and assisting commercial drivers to make health and wellness lifestyle changes, with a view toward maintaining and retaining a healthy workforce and fostering safe driving practices on the nation’s highways. Two such programs are highlighted here: the FMCSA-ATRI co- sponsored Gettin’ in Gear program and the Occupational Athletics program of driver athletes designed for commercial truck and bus drivers. Gettin’ in Gear Wellness Program. This program for commercial drivers focuses on principles of general wellness, health, and fitness for CMV drivers, for their employers, and for their families. The formulation of the Gettin’ in Gear wellness program was sponsored by the FMCSA, and it was initially developed by Susan Roberts (a dietician) and Jim York (a truck- ing safety officer) at the NPTC (Roberts and York). The Gettin’ in Gear program was further developed by ATRI. From the Get- tin’ in Gear program, the ATRI developed a 3-hour train-the- trainer course intended for commercial carrier staff personnel (e.g., human resources, occupational health, safety and risk managers, driver managers, and other company officials). Get- tin’ in Gear is also designed for presentation to truck and motor coach drivers themselves (Krueger and Brewster 2002; Brewster and Krueger 2005; Krueger, Brewster, and Alvarez 2002). The intent of the Gettin’ in Gear train-the-trainer course is to explain the most common health threats facing commercial drivers and to entice employers and drivers to take proactive action to participate in a personal wellness, health, and fitness program. The Gettin’ in Gear train-the-trainer course provides preliminary guidance on how to get started on such a program. An executive level Gettin’ in Gear course, normally offered to company officials, includes additional discussion of direct and the indirect health care costs associated with not having a corporate wellness program and addresses cost implications of implementing such a program. The Gettin’ in Gear program addresses lifestyle health risks associated with commercial driving careers. Important threats to commercial drivers’ health and fitness discussed in the course are as follows: • Smoking and tobacco use • Obesity/being overweight • Hypertension (high blood pressure) • Poor eating habits, poor diet and nutrition • Alcohol, drugs, other chemical substances • Lack of physical activity/physical fitness • Psychological stress and mental fitness Gettin’ in Gear provides preventive medicine guidance on what to do about these health risks and points the way to developing a personal wellness plan. Basic Gettin’ in Gear premises are as follows: • Drivers’ health behavior patterns are precursors to safe driving practices. • CMV driver health is important to ensure alert, attentive driving for overall safety on the nation’s highways. • Preventing health problems preserves the nation’s valuable CMV workers. • Driver wellness programs foster healthy employees, improve lifestyles, help contain health care consequences and costs for workers, their families, and employers, and they foster a positive corporate climate of concern and excellence. The Gettin’ in Gear wellness program is a personalized driver wellness program built around four health principles, called the four Rs of driver wellness. The 4-R Road Challenge is designed to help drivers attend to health and fitness matters while at home and while traveling on the road. The four Rs in Gettin’ in Gear are • Refueling: learning better eating practices so the body per- forms at its best, giving extra energy and better alertness, especially while driving. Offers nutrition information on lists of food and provides recommendations for healthy diets. 29

• Rejuvenating: improving one’s physical self through exer- cise, maintaining regular exercise and movement activities to preserve one’s health, and to remain physically fit. Sam- ple exercises drivers can do are described. • Relating: understanding the importance of relationships; and how to enhance relationships with others, both per- sonal and professional, as they impact our personal stress levels, our health, and our performance on the job. • Relaxing: becoming calmer in a fast paced world, at home and at work, by learning to recognize, control and manage our responses to the many stresses we face. Describes stress alleviation techniques, and hints to avoid road rage. For drivers, the Gettin’ in Gear wellness program is about the following: • Discovering an improved way of life • Finding one’s own optimal health • Experiencing one’s own personal journey • Having more energy, most of the time • Dealing with stress, anticipating it, managing responses to it • Feeling better about oneself, and just feeling good • Enjoying retirement, anticipating it rather than dreading it Drivers as Road Athletes. The Road Athlete System™ and the Bus Athlete System™ are two interactive driver health and safety training programs that specifically address the unique “roadblocks” facing truck and bus drivers that may prevent drivers from living a healthy lifestyle. This interactive training approach treats truck and bus operators as “road ath- letes” or “bus athletes,” encouraging participants to become involved in improving their own health and safety. Partici- pants are to imagine themselves as athletes, their playing field is the road, and they are to envision themselves as being the quarterback of their bus or truck. Each work day the drivers are to participate in a new game (outlined in a workbook) with a new opportunity to achieve personal health and safety goals. Participant drivers who become involved are given two audio CDs containing a motivational talk and a roundtable discussion among bus/truck drivers and safety experts focusing on the lifestyle and safety of professional drivers. Drivers are then given an Athlete System Game Book with 12 months of games (lessons) designed for the truck driver or bus operator to encourage them to make simple lifestyle changes in his/her own health and safety. Every workday, for 1 year, the book presents the bus or truck driver with another lifestyle and a safety factor along with short goals to accomplish. The 12 lifestyle factors covered in the driver athlete systems include nutrition, physical exercise, mental fitness, stress reduction, attitude and happiness, sleep, substance abuse, time management, motivation, disease prevention, weight/ obesity, and relaxation. The safety factors include weather conditions, driving regulations, passenger safety, compli- ance, pre- and post-trip inspections, injury prevention, and employee-employer relations. Each factor is accompanied by a “motor-vator” (a catch phrase) to increase driver interest in each topic. Daily tips and motor-vators are concise, easy to understand, and entertaining to read, and they express a day-by-day, step-by-step, and goal- by-goal approach to altering the driver’s lifestyle so as to be more healthy, and they encourage safe driving. Games include physical exercises, counting nutritional intake indicators, and stress reduction activities. As the drivers score their daily game goals, they become winners in the Game of Life. The intent of the road and bus athlete systems is to encourage commercial drivers to exercise control over their physical and mental well- being (lifestyle factors) and, at the same time, gain greater safety awareness and know-how (safety factors). These driver athlete health training systems were developed by Susan and Ron Shapiro and Mark and Lori Everest at Occupational Athletics, LLC, in Harrisburg, Pennsylvania (Shapiro 2005; Everest et al. 2005 www.occupationalathletics.com). The research team found that numerous trucking, bus, and transit companies are involving their drivers in these road athlete programs and beginning to report positive results. This approach warrants further scrutiny and monitoring to determine success rates. 2.8.10 OSHA Web-Based Assistance on Safety and Health Topics Recently, the Occupational, Safety and Health Adminis- tration (OSHA) posted on its website a Safety and Health Topics Page intended to provide information to help safety managers and others demonstrate the value—or “the bottom line”—of safety and health to management. More details about this OSHA initiative can be found in Appendix D. 30