Transit Operator Health and Wellness Programs (2004)

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7 CHAPTER TWO REVIEW OF LITERATURE This chapter summarizes the current literature on the topic of health and wellness issues facing transit operators and the interventions used to address these issues. The litera- ture review revealed a limited number of transit-specific studies. Much of the research about transit operator health and well-being has been completed by teams of researchers at the University of California at Berkeley, with operators at the San Francisco Municipal Railway as the primary re- search subjects. The review integrates an examination of health risk factors for operators, workplace issues for workers in similar situations as transit operators, and chal- lenges and success stories about how employers have ad- dressed specific workplace health and wellness issues to the benefit of the employee and employer. The first portion of the literature review focuses on the nature of the job and how job requirements set forth by federal regulations determine who gets to operate commercial vehicles in the United States. This is followed by a review of health risk factors that influence the operator’s ability to per- form and retain his or her job. Success stories of employers that have taken on the challenge of improving their em- ployees’ health and wellness, several in union environ- ments, are highlighted in the final section of the review. The literature on health and wellness contains numerous specialized terms. Although brief definitions of many terms are included in the text, definitions of others can be found in the Glossary of this report. NATURE OF THE OPERATOR JOB Previous TCRP reports cited examples of how various as- pects of the transit operator position compromises the per- ceived quality of employee health. In one report, TCRP Synthesis of Transit Practice 33: Practices in Assuring Employee Availability (1), the impact of tight schedules on driver health behaviors was noted as an area of paramount concern by bus operators. For instance, operators noted that the lack of time for breaks at layover points contrib- uted to poor eating habits. The report stated that given only a few minutes to eat, operators often resort to eating junk food rather than nutritious alternatives. TCRP Report 81: Toolbox for Transit Operator Fatigue (2) provides a view as to why operator fatigue is such a health and safety issue. The report acknowledges that transportation organizations have always needed employ- ees to work long and unusual hours. These long and un- usual hours, often uncertain from day to day, create the need for operators to work when their bodies tell them they should be sleeping. The report points out that shift work- ers, those who work outside of the typical 8 a.m. to 5 p.m. workday, are especially prone to health problems, the most common of which are upset stomach, constipation, and ul- cers. According to that report, shift work is also known to aggravate other health problems such as cardiovascular disorders and diabetes. A third TCRP study, TCRP Report 77: Managing Transit’s Workforce in the New Millennium (3), cites how the stress of uncertain work schedules contributes to a lessened sense of well-being for operators. The tendency of transit agencies to hire operators initially as part-time em- ployees whose schedules are very unpredictable, many times in a split-shift configuration, often for many years, creates a stressful situation for these employees). In the 1997 National Institute for Occupational Safety and Health (NIOSH) publication, Plain Language About Shiftwork, the authors reported that because shift workers are often tired as a result of their work schedules, they have an increased possibility for errors and accidents, and therefore present a risk to themselves and the public. According to the authors, body functions slow down during the nighttime and early morning hours; therefore, a combination of sleep loss and working at the body’s low point can cause excessive fa- tigue and sleepiness. They go on to state that although some people believe that permanent night-shift workers adapt to their schedules, research shows that most permanent night- shift workers do not. In other words, there are many nights when these employees work when they feel tired and sleepy. Some research has shown that specific health problems, such as heart and gastrointestinal diseases, are more preva- lent in shift workers than in day workers (4). Rotating shifts is another problem for workers, espe- cially if shift changes occur rapidly and the worker does not have a chance to adjust to the schedule. In addition, backward or counterclockwise rotations (where the em- ployee is scheduled to report earlier) appear to be more dif- ficult for the worker than forward or clockwise rotations (where the employee is scheduled to report later). Back- ward rotations tend to work against the body rhythm by forcing the employee to go to sleep earlier and earlier (4). One research team with extensive experience in study- ing the health and well-being of urban transit operators concluded that urban transit operators’ medical symptoms

8 and conditions exceed those of other occupational groups, partly as a result of working conditions. The researchers further concluded that a cycle of poor working environments, reduced health and well-being, and lowered efficiency result in greater costs to employees and employers (5). FEDERAL REGULATIONS The Federal Motor Carrier Safety Regulations of the U.S. Department of Transportation, Title 49 of the Code of Fed- eral Regulations, Part 391, Subpart B 391.15, outlines physical requirements for drivers. The list of requirements includes, but is not limited to, the following: “A person shall not drive a commercial motor vehicle unless he/she is physically qualified to do so . . . ” The regulations go on to specify when a person is qualified, including: • No established medical history or clinical diagnosis of diabetes currently requiring insulin for control. • No current clinical diagnosis of any cardiovascular disease of any variety known to be accompanied by dizziness, shortness of breath, collapse, or congestive heart failure. • No current clinical diagnosis of high blood pressure likely to interfere with his or her ability to operate a vehicle safely. • No mental, nervous, organic, or functional disease or psychiatric disorder likely to interfere with his or her ability to drive safely (6). RISK FACTORS AND THEIR IMPACTS The following discussion gives insight into the nature and severity of health risk factors and personal and business impacts of illnesses highlighted in the federal regulations, as well as other disabling conditions. Musculoskeletal Problems Statistics provided by the federal Occupational Safety and Health Administration (OSHA) and the U.S. Bureau of La- bor Statistics (BLS) show that each year 1.8 million em- ployees experience injuries resulting from overexertion or repetitive motion. Of these, 600,000 require time off from work (7). Musculoskeletal problems such as carpal tunnel syndrome and back strains make up one-third of all work- place injuries. Musculoskeletal injuries are estimated to cost between $15 billion and $20 billion per year in work- ers’ compensation claims, making them among the most costly workplace problems. The cost of these injuries to the employer and to affected employees has given rise to in- creased interest in ergonomics, which can be defined as the science of fitting the job to the worker (7). In a study of 195 participants, with two-thirds being op- erators selected from the membership of an urban transit union in California, 80.5% were found to be experiencing back or neck pain at the time of physical examination, in contrast to a group of nonoperators, of whom 50.7% had such pain. Operators were most distinctive for movement- related pain in the cervical spine area (8). Stress Research shows that common tensions—whether the result of 50-h workweeks, demanding supervisors, or personal concerns—can create a sense of unease or stress. Continu- ous high levels of stress can and do cause illness, poor judgment, nonproductive relationships, and substandard performance. Many times a day, a person can experience stress-causing events that signal the body to produce nu- merous biochemical changes, mainly the hormones adrena- line and cortosol. Experts in the stress management field point out that a given circumstance, however, may be stressful to some people and not to others. Their position is that it is not the event that causes stress; rather, the per- son’s reaction to the event causes stress. Stress reactions vary, but they often include headaches, muscle tension, fa- tigue, insomnia, fuzzy thinking, and emotional and other problems. Also, stress can increase the severity of already existing illnesses (9). According to the NIOSH report, Stress . . . At Work, 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 em- ployee. The report goes on to say that now more than ever, job stress poses a threat to employees’ health and, in turn, to the health of organizations (10). One stress management expert states that stress levels in the workplace are getting worse as a result of a number of factors, including poor management training and practices, feelings of a lack of control over the work environment, and corporate cultures that value equipment over people (11). According to the American Institute of Stress, a nonprofit organization established to serve as a clearing- house for information on all stress-related subjects, the costs of stress to the economy can be seen most vividly in rapidly increasing health care costs. This organization es- timates that up to 90% of physician visits are stress-related. The latest available statistics from the BLS show that the median work absence owing to stress was 23 days in 1997, more than four times the median absence for all occupa- tional injuries and absences (9). The American Institute of Stress also reports that stress costs U.S. businesses between $200 billion and $300 bil- lion annually in lost productivity, increased workers’ com-

9 pensation claims, turnover, and health care costs. Further- more, some stress may be inherent in the nature of the job and how the individual perceives events that could be stressful on the job. Although it is commonly believed that stress often stems from a person’s reaction to a situation, research conducted by NIOSH reveals six aspects of work that, handled poorly, can generate stress. • Task design, including heavy work loads, infrequent rest breaks, long work hours, shift work, and hectic or routine tasks; • Management style, including poor communication, lack of family-friendly policies, and workers’ lack of participation in decision making; • Personal relationships, including poor social envi- ronment and inadequate support from coworkers and supervisors; • Work roles, including conflicting and uncertain job expectations, and too much responsibility; • Career concerns such as inadequate job security and a lack of opportunity for growth and advancement; and • Environmental conditions, including unpleasant or dangerous physical conditions (10). One author asserted that employees in safety-sensitive jobs are particularly vulnerable to cumulative stress and psychological trauma as a result of the frequency and se- verity of stressful situations they encounter in these occu- pations (12). Researchers from the University of Califor- nia, Berkeley, Department of Epidemiology conducted 81 observational work analyses to measure stressors experi- enced by operators at the San Francisco Municipal Rail- way transit system. This group defined stress factors as hindrances to task performance owing to poor work or- ganization or technological design. Stressors included work barriers, defined as obstacles that cause extra work or unsafe behavior; time pressure; monotonous conditions; and time binding, defined as control over timing (13). Researchers from the University of California Irvine’s School of Social Ecology found a high degree of associa- tion between exposure to peak traffic conditions and ab- normal on-the-job levels of certain chemical compounds in the urine of urban bus operators. Those relationships re- main even after incorporating controls for other possible factors such as job seniority, age, and smoking. In addition, perceived reductions in control on the job partially account for the linkages between traffic congestion and stress (14). Some individuals find healthful ways to cope with stressful events; others tend to self-medicate with drugs and alcohol. Often workers do not realize when a stressful situation is becoming a problem. An expert in the field states that, even with awareness, some workers are reluc- tant to seek assistance for two reasons: a macho culture that pervades many occupations and a general bias against mental health counseling (15). Workplace Violence Homicide is the third leading cause of fatal occupational injury. According to the BLS, there were 677 workplace homicides in 2000, accounting for 11% of the 5,915 fatal work injuries in the country. Also, from 1993 to 1999, an average of 1.7 million nonfatal violent acts were reported at workplaces. According to NIOSH, workers most at risk are those whose jobs involve routine contact with the pub- lic or require an exchange of money. Also at increased risk are those working alone or in small numbers, working very late or very early hours, or working in high-crime areas. Another risk factor is having a mobile workplace. Each of these circumstances is characteristic of the transit operator position. Workplace violence is now being seen not as just a crime issue but also a public health issue for which em- ployers need to prepare. Benefits of this preparation in- clude • Risk reduction, • Improved employee morale, • Increased feelings of security, • Enhanced supervisory skills, • Early identification of issues, • Business cost reduction, • Improved conflict resolution capability, and • Reduced legal liability (16). Smoking There is a growing body of research showing that employ- ees who smoke affect businesses negatively. In 1992, the U.S. Environmental Protection Agency (EPA) classified environmental tobacco smoke as a Group A carcinogen, ranking smoke among the most dangerous cancer-causing agents in humans. The Centers for Disease Control estimates that smoking causes up to 40,000 heart disease deaths among nonsmokers. Environmental tobacco smoke is also known to aggravate the symptoms of diseases such as asthma, bronchitis, and various allergic conditions. Ex- penditures in the United States directly associated with smoking are estimated at $72 billion annually (17). An employee who smokes costs the employer at least $1,000 extra per year in total excess direct and indirect health care costs. This amount includes $75 billion in direct health care costs and $82 billion in lost productivity costs. Furthermore, smoking-related diseases claim an estimated 430,700 American lives each year. It is directly responsible for 87% of all instances of lung cancer and causes most cases of emphysema and chronic bronchitis (18).

10 The EPA has concluded that the widespread exposure to secondhand smoke in the United States presents serious and substantial public health problems. The toxins in to- bacco smoke kill more than 440,000 people per year in the United States. Nonsmokers exposed to secondhand ciga- rette smoke inhale those same toxins, with harmful health effects. Secondhand smoke causes more than 3,000 lung cancer deaths annually, as well as exacerbation of lung dis- ease in nonsmoking adults and respiratory problems in children. Secondhand smoke also causes 35,000 heart dis- ease deaths in nonsmokers each year (18). One research study conducted at 44 worksites explored the concept that a number of social influences may account for at least some of the differences in smoking prevalence and smoking cessation among blue-collar workers com- pared with the experiences of other workers. The study re- port cites NIOSH data and other statistics indicating that blue-collar workers, including transportation operators, are more likely to be smokers (37% for men and 33% for women) than are white-collar workers (21% for men and 20% for women). Four variables were measured: (1) social support for quitting, (2) pressure to quit smoking, (3) re- wards for quitting, and (4) nonacceptability of smoking. The results appear to indicate that social influences that promote quitting smoking are less prevalent among blue- collar workers than among other workers. The researchers theorize that social norms or standards for behaviors may help to shape behavior. Worksite culture has been shown to influence the amount that workers smoke. Coworker dis- couragement of quitting has been shown to lower one’s confidence in his or her ability to quit smoking. The re- searchers point out that building social support for quitting may be especially important in promoting smoking cessa- tion among blue-collar workers. They also suggest that de- veloping smoking policies and programs may help to cre- ate an environment of coworker support for quitting (19). Drug and Alcohol Abuse The misuse of drugs and alcohol in the United States is considered by many to be at the epidemic level. Each year, more than 1 million persons are arrested on drug and alco- hol charges, and more than 10,000 die as a result of using illegal drugs. The White House has a drug czar, an individ- ual appointed to lead the nation’s national war on drugs. Several states and cities have appointed their own drug war leaders in an effort to stem the tide of prohibited drugs and excessive alcohol use. The realities of drug and alcohol abuse are evident through the media and through personal experiences of coworkers, family, and friends. In the trans- portation industry, drug and alcohol abuse is both a public safety and personal health concern. The number and devas- tating effects of accidents and incidents triggered by the abuse of such substances illustrate that this is a health and wellness issue requiring significant attention and resources (20). With the passage of the Omnibus Transportation Em- ployee Testing Act by Congress in 1991, transit agencies have paid increasing attention to substance abuse by em- ployees in safety sensitive positions. The vehicle operator position is designated safety sensitive. In compliance with the act, the FTA established regulations that require recipi- ents of specific FTA funds to implement an antidrug and alcohol program to deter and detect the use of prohibited drugs and alcohol by transit employees. Required drug testing falls into 6 categories: (1) pre-employment, (2) random, (3) post-accident, (4) reasonable suspicion, (5) return-to-duty, and (6) follow-up. Required alcohol testing falls into five categories: (1) random, (2) post-accident, (3) reasonable suspicion, (4) return-to-duty, and (5) follow-up (21). Each transit agency’s drug and alcohol program must include a policy that is communicated to all employees. One transit agency’s 2003 drug and alcohol policy states Drug and alcohol use can have profound effects on the health, work, and personal life not only of the abuser but also on the abuser’s family, friends, and the public at large. Employees should be aware of the signs and symptoms of drug and alco- hol problems, and of available methods of intervening when a substance abuse program is suspected (22). Fatigue Sleep deprivation is reportedly widespread in the United States. Since 1900, the average amount of sleep has de- creased from 9 h to approximately 6.4 h, even though the average adult needs approximately 8 h. The National Sleep Foundation statistics indicate that sleep-deprived adults are likely to fall asleep while on the job or doze off while driv- ing. Inadequate sleep can result in health and safety risks, decreased productivity, and disruptions in relationships owing to irritability. Reduced sleep negatively affects cog- nitive abilities, critical thinking, and problem-solving abili- ties. Shift workers are particularly at risk for driving acci- dents. One author cites recent research from Great Britain, which suggests that sleepiness and fatigue surpass alcohol and drugs as the most identifiable and preventable cause of transportation accidents. Education is the most important tool for combating fatigue and sleep deprivation. Few peo- ple understand the long-term negative effects on health and well-being. Education can provide employees with the knowledge they need to plan for getting sufficient rest (23). According to a study conducted by Circadian Technolo- gies, Inc.—a research and consulting firm specializing in assisting organizations with around-the clock operations— one-fifth of North American employees, some 24 million workers, work outside of the standard 9-to-5 business day.

11 The extended hours of operation have increased the health problems among shift workers, which translates into ele- vated accident rates, absenteeism, turnover, and insurance premiums (24). The National Commission on Sleep Disorders estimates that 70 million Americans suffer from sleep deprivation. Work-related problems such as increased stress, inatten- tiveness, and reduced productivity are often caused by a lack of or the poor quality of sleep. According to the head of the Mayo Clinic’s Sleep Disorders Center in Rochester, Minnesota, if a person relies on an alarm clock to wake up, he or she is not getting enough sleep. The clinic defines adequate sleep as “. . . that amount which, when you at- tain it on a steady basis, produces a full degree of daytime alertness and a feeling of well-being the following day.” The clinic asserts that sleep deprivation is cumulative and over time results in “sleep debt.” In other words, a person who needs 8 h of sleep and only gets 7 h has at the end of the workweek a debt of 5 h. However, it is much more ef- fective to maintain a consistent pattern of sleep than to try a catch up strategy on days off. A British sleep research center found that sleep deprivation noticeably impairs one’s ability to comprehend rapidly changing situations, increases the likelihood of distractions, contributes to rigid thinking, and reduces creative problem solving. Providing nap rooms for workers may be helpful, but employers must still educate employees and managers about the dangers and signs of sleep deprivation, and monitor and adjust work scheduling practices (25). TCRP Report 81, which focuses on fatigue in the transit industry, states that when faced with long service hours and a limited pool of operators, many transit agencies rely heavily on overtime to provide service. Extended periods of overtime increase the likelihood that operators may not be fully alert. Researchers in Australia determined that af- ter a person has had 17 h of sustained wakefulness, hand– eye coordination decreased to a level equivalent to that of someone with a blood alcohol level of 0.05%, and after 24 h to a level equivalent to 0.1%, a level that exceeds the limit for presumed intoxication in most of the United States. The consequences for operator fatigue can be sig- nificant for operators, passengers, and the transit agency. In 1995, two subway trains collided when a train operator failed to respond to a stop signal and collided with a train standing ahead of him on the same track. The operator was killed, and 69 other people were treated for injuries sus- tained in the accident. National Transportation Safety Board (NTSB) investigators found that the operator in this accident, which brought damages that exceeded $2.3 mil- lion, had fallen asleep at the controls (2). In some cases, operator fatigue stems from factors other than a lack of sleep. The NTSB found other fatigue-related causes for two light-rail accidents with injuries. In one case, the operator was found to have undiagnosed sleep apnea. In the second case, the NTSB concluded that the ef- fects of prescription pain-relieving medications and/or re- cent cocaine use impaired the performance of the train op- erator. The transit system estimated that the cost of each accident exceeded $900,000. Operator fatigue, whatever the cause, is clearly a health, safety, and economic issue for transit operators, their agencies, and the public (2). Obesity Obesity, an excess of body fat relative to lean body mass, is a growing health concern for both women and men. Obesity, often determined by the body mass index (BMI), is defined as a BMI of greater than 27.3 in women and greater than 27.8 in men. One of the strongest reasons for treating obesity as a disease is that it is a risk factor for many other diseases, including diabetes, hypertension, car- diovascular disease, sleep apnea, and possibly some can- cers. Studies have shown that obese individuals are three to eight times more likely to have hypertension than are nonobese individuals. Nearly 50% of people with hyper- tension are obese (26). Diabetes Approximately 16 million Americans, about 6% of the population, have diabetes, a chronic disease in which the body does not produce or properly use insulin, a hormone that is needed to convert sugar, starches, and other food into energy. It is estimated that approximately 5.4 million of these people do not know they have the disease. Diabe- tes is the sixth leading cause of death in this country. In addition, complications of diabetes such as kidney failure, blindness, loss of limbs, and strokes in turn lead to many dis- abilities that restrict the employment choices of working adults. Total health care and related costs for the treatment of diabetes reaches approximately $100 billion annually. Some $55 billion of that amount covers costs such as disability payments, time lost from work, and premature death (27). As stated earlier, federal regulations prohibit individuals whose diabetes cannot be controlled without insulin injec- tions from operating interstate commercial vehicles. Depression Statistics show that depression is on the rise in the work- place. In a 1999 report by the Society for Human Resource Management (SHRM), in collaboration with the National Foundation on Brain Research, Depression in the Work- place Survey, 8 of 10 human resources (HR) professionals reported that depression had been a problem for one or more employees during the past 3 years (28,29). Costs as-

12 sociated with depressive disorders—illnesses experienced more by women than men—are on the rise (30). The SHRM researchers estimated that depression costs em- ployers from $30 billion to $40 billion each year. Although the costs of treating depression are high, the costs of un- treated depression are much higher. When depression is not managed, employees may complain about a variety of physical problems. The SHRM report estimates that up to 50% of all visits to primary care doctors are made in regard to conditions caused by or exacerbated by mental prob- lems. The National Mental Health Association reports that people with depression are four times more likely to suffer heart attacks than are those with no history of depression. According to the director of the American Institute for Cognitive Therapy—a group of psychologists and psycho- therapists who treat depression and other disorders— depressed employees tend to have higher absenteeism, be less creative, and be more argumentative (29). Cardiovascular Disease Medical researchers estimate that one-quarter of Ameri- cans have some form of cardiovascular disease. Hyperten- sion is at the top, with coronary heart disease (CHD) sec- ond. These conditions account for approximately 250,000 deaths each year (31). Hypertension, or high blood pres- sure, a condition in which the force with which blood flows through the walls of blood vessels remains elevated above normal levels over time, can be a risk factor for heart and kid- ney disease. Left untreated, hypertension leads to damage and weakening of the walls of the arteries, making them vulner- able to collection of materials that can cause life-threatening clots. The prevalence of hypertension in African– Americans is among the highest in the world. According to the American Heart Association, as many as 30% of all deaths in African–American men and 20% of all deaths among African–American women can be attributed to hy- pertension. Contributing factors to hypertension include high cholesterol, obesity, and lack of exercise (32). Furthermore, uncontrolled hypertension is the primary diagnosis for approximately 25% of individuals with chronic kidney disease, accounting for 26% of all new cases of kidney failure each year. Hypertension can also be a major cause of strokes. The American Stroke Association reports that African–American men are twice as likely as Caucasians to have a stroke. The 1998 National Center for Health Statistics data related to total deaths in various mi- nority male groups in the United States (i.e., deaths caused by diseases of the heart) reveal the danger of uncontrolled hypertension: • Asian Pacific Islander, 36.1%, • African–American, 34.2%, • American Indian/Alaska Native, 27.9%, and • Hispanic, 25.3% (32). However, some risk factors for CHD are preventable, including high cholesterol, hypertension, smoking, uncon- trolled diabetes, and obesity. The more risk factors an indi- vidual has, the more likely he or she will develop CHD. Opportunities to prevent CHD include eating healthfully, increasing physical activity, not smoking, and weight con- trol (33). HEALTH PROMOTION PROGRAMS: BENEFIT FOR EMPLOYEE OR EMPLOYER? 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, HR consul- tancy Hewitt Associates estimated large employer (nor- mally not fewer than 100 employees) costs at $4,026 per employee, three-fourths of the cost of premiums; employ- ees were estimated to pay an average of $1,401 more in costs in 2002 than in 2001 (34). One recent workplace health promotion author reported 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 to change unhealthful behaviors. The author states that the primary goal of any wellness program should be to return the highest-risk people to low- risk status while helping the other 90% maintain a low- health-risk lifestyle. Getting that 10% of the employees to participate in managing their health and well-being, how- ever, can be a particularly challenging task (35). The Wellness Council of America, a nonprofit health promotion organization, emphasizes that although an em- ployer cannot force employees to participate in a health and wellness program, the employer can tie such participa- tion to an employee’s being able to participate in the em- ployee benefits package. The organization estimates that the typical benefits package costs a company roughly $4,000 per person per year. Considering that outlay of ex- penditures, the council believes that a company has the right to ask that individual 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 conditions following these screenings or appraisals (36). A survey of 1,035 major employers found that 85% of re- sponding employers offered some form of health promotion, and 75% use health risk assessments. The survey also found that incentives for employees making healthful lifestyle changes and the penalties for those engaging in high-risk behaviors, such as smoking, are becoming more prevalent.

13 A variety of factors associated with unhealthy employ- ees can contribute to costs including • Absenteeism, • Medical expenses, • Distress to other employees during absence, and • Cost of replacement (36). Health promotion is typically approached in two ways: (1) decrease external risks, such as carcinogens and pro- vide adequate on-the-job safety measures; and (2) reverse risk behaviors, such as smoking and physical inactivity. Such efforts can matter a great deal. For example, DuPont found absenteeism 10% to 32% higher among its employ- ees 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 imple- menting a wellness program at 41 of its sites, DuPont had a 14% decrease in absenteeism. Similarly, the Union Pacific Railroad’s health promotion program was instituted when the company determined that its medical costs per em- ployee were almost twice the national average. With a medical self-care program the company experienced a sav- ings of $1.26 million annually (36). From 1999 to 2001, the DaimlerChrysler/UAW Well- ness Program realized a savings of $4.2 million among bargaining union employees who participated. Since the program was piloted in 1985, 44,298 employees have par- ticipated. There were 32,752 active participants in 2001 (37). The company contracts with health and fitness busi- nesses to administer the wellness program, which is volun- tary and confidential. Four goals underpin program activi- ties. • Empower employees to be wise health care consum- ers and improve their health, • Keep low-risk employees in the low-risk category, • Target high-risk employees with focused interven- tions, and • Provide cost-effective wellness activities designed to contain health costs. The DaimlerChrysler program employs the following various incentives and techniques to increase and maintain employees’ participation in the program: • Gifts distributed at health screenings; • WELLBUCK$, “money” earned for participating in activities that can be redeemed for prizes such as gym bags, sweatpants, first aid kits, and polo shirts; • Targeted marketing based on prior participation; • Incentives for participating employees who bring in new participants; • Convenient access to screenings in the worksite; and • Interactive, fun, and nonthreatening activities. A study conducted for Johnson & Johnson that evalu- ated long-term financial and health effects of large-scale wellness programs showed positive results. The study re- viewed medical claims for 18,333 domestic wellness pro- gram participants from 1995 to 1999. Medical expendi- tures were evaluated for up to 5 years before and 4 years after the wellness program began. Employees participating in wellness activities had significantly lower medical costs and achieved improvements in several health risk catego- ries: high cholesterol, hypertension, and smoking. Johnson & Johnson averaged $8.5 million annually in savings for the first 4 years of the program. Savings came primarily from lower administrative and health care utilization costs. As a result of linking the program to health care benefits and financial incentives, the company saw participation rise from 26% in 1995 to 90% during the study period. Fi- nancial incentives included a $500 medical plan discount for employees who completed a health risk assessment and enrolled in a high-risk intervention program, if recom- mended. Another Johnson & Johnson study showed health risk factor reductions in 6 of 13 risk categories within the first year of the program: tobacco use, sedentary lifestyle, hypertension, high cholesterol, low dietary fiber intake, and poor motor vehicle safety practices (38). Steelcase Inc., a manufacturer of custom office furni- ture, combines long- and short-term disability, workers’ compensation, medical case management, and Family and Medical Leave Act administration in a way that helps to keep health and wellness costs in check. Comerica, a fi- nancial services provider, has a corporate health manage- ment department that oversees workers’ compensation, short- and long-term disability, wellness and health, em- ployee assistance, and violence-in-the-workplace pro- grams. The health management department also oversees compliance with the Family and Medical Leave Act and the Americans with Disabilities Act. The company takes a view of employee health as a continuum—believing that every aspect, from employee wellness to return-to-work, is better managed through such a view (39). TRANSIT INDUSTRY HEALTH AND WELLNESS PROGRAMS TCRP Report 77: Managing Transit’s Workforce in the New Millennium, published in 2002, highlighted a number of health and wellness programs at transit agencies (3). • The Healthy UTA program is a quality-of-life pro- gram at the Utah Transit Authority (UTA) in Salt Lake City, Utah, that has been operational since 1990. The 10-page booklet about the comprehensive health and wellness program includes a letter of in- troduction signed by the HR director, the Amalga-

14 mated Transit Union (ATU) president, and the well- ness program administrator. Activities include 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, a total of 1,017 employees participated in one or more of the well- ness activities. • The health and wellness program at the Metropolitan Area Rapid Transit Authority, in Atlanta, Georgia, is a comprehensive effort aimed at addressing employee well-being as a personal and bottom-line issue. Twice-a-year health fairs at facilities, as well as monthly massages, brown-bag health education classes, and monthly health promotion newsletters sent to each employee are all well received. With fit- ness facilities available at each location, employees can maintain healthful levels of physical activity at their own pace. • By integrating community involvement, employee wellness, and employee-recognition activities into a program titled Champions of Transit, the Regional Transportation District in Denver, Colorado, commu- nicated its commitment to being a positive force in the community and to its employee health, well- being, and development. • Health Express, an employee-committee program at Pierce Transit in Tacoma, Washington, sponsors health education and support aimed at helping em- ployees make healthful lifestyle choices. Blue-Collar Workers Studies reveal that blue-collar workers are less likely to participate in worksite health promotion programs than are white-collar workers. One study focused on the percep- tions of the worksite health climate held by blue-collar workers compared with perceptions held by other workers. The goal was to gain knowledge that may be helpful in tai- loring worksite wellness programs to better serve blue- collar workers and determine how to modify the work en- vironment to promote worker health. The workers were employed in a manufacturing setting, were members of the United Auto Workers, and were engaged in welding, as- sembly, machine operation, maintenance, and painting (40). A random sample of 497 workers (330 blue-collar and 167 white-collar), with an average age of 44.5 years, were surveyed using the Worksite Health Climate Scales instru- ment, with a 51% response rate. The company did not offer a formal health promotion program, but was designated a smoke-free workplace. Results showed that blue- and white-collar workers viewed the worksite health climate quite differently, with blue-collar workers perceiving the climate less positively. White-collar workers perceived more flexibility to exercise, a more healthful norm for nu- trition, and more support from supervisors and coworkers for healthful behavior. In contrast, blue-collar workers had a higher score on only one factor, smoking norms. Twenty- eight percent of blue-collar workers were smokers compared with 18% of white-collar workers. Perceptions of an antismoking sentiment were stronger among blue- collar workers (40). The city of Birmingham, Alabama, as part of its health promotion program (Good Health Program) for 4,000 city employees, developed a comprehensive antihypertensive educational intervention. Fifty percent of all employees were African–Americans and 20% of all employees were women. The goal of the program was to reduce risk factors for cardiovascular disease among these workers. After identifying barriers to hypertension control—low literacy, difficulty in understanding the need for treatment in the ab- sence of symptoms, and various health beliefs and priori- ties—a tailored educational program was designed and in- troduced. Education focused on lifestyle changes and the need for medical care. Although the program was offered to all employees with hypertension, 130 chose to enroll, with 81 completing the program. Those 81 participants were matched by age, sex, race, and baseline blood pressure with 81 nonparticipating patients with hypertension. The program was evaluated by pre- and post-education changes in blood pressure. The greatest benefit was seen in African– American workers, with a reduction of 7.4 mm Hg (milli- meters of Mercury), the measure of blood pressure, and unskilled workers at 7.7 mm Hg. The program evaluation concluded that a culturally appropriate, educational pro- gram tailored to the needs of minority and low-income populations may increase control of hypertension (41). Ergonomics The University of Michigan Center for Ergonomics re- ported that an ergonomics program is useful because it promotes the health and well-being of the work force—that is, many cumulative trauma disorders (CTDs) are prevent- able. Therefore, workplace adjustments and education can contribute to lowering employee injury claims (7). Ergo- nomic specialists focus on finding ways to ensure that the design of equipment and work processes takes into consid- eration the capabilities and limitations of employees. They attempt to eliminate or at least minimize as many repetitive motions as possible, even when the motion does not di- rectly cause injury. An effective ergonomics program can significantly reduce the number and types of muscu- loskeletal injuries. Best practices in ergonomics share some elements: upper management support, employee participa- tion, an early reporting system, and proactive hazard evaluation (42).

15 After 1 year of ergonomic training, an Illinois-based Mitsubishi automotive manufacturing plant saw a 25% drop in CTDs over the previous year. The Stationery and Office Supplies division of 3M experienced a drop in claims of approximately 60% over previous years follow- ing the introduction of an ergonomics program. The city of San Jose reported a drastic reduction in its workers’ compensation claims. In addition to the benefit of knowing how to manage their health, employees tend to see an em- ployer that has an ergonomics training program as caring about employees. According to the chief executive officer (CEO) of the Injured Workers Insurance Fund, the largest workers’ compensation insurer in the state of Maryland, workers’ compensation claims are often filed out of anger or frustration at the employers’ lack of attention to em- ployee’s well-being. An official of USAA, an insurance and financial services firm, stated that one employee came up and hugged him, stating that her life was completely changed because she did not have to hurt anymore at the end of the day (7). Ergonomic experts report that the greatest value comes from ergonomics training that is job specific. NIOSH pro- vides an 11-question “Workstation Ergonomics Checklist,” which can serve as a starting point for identifying potential problem areas that should receive further investigation and attention. One strategy found effective in ergonomics man- agement is to establish programs for solving problems identified by employees. Some employers with multiple sites have ergonomic committees at each site. Their em- ployees are encouraged to look for potential issues, to lis- ten to their bodies, and to work with management to re- solve issues (7). TCRP Report 25: Bus Operator Workstation Evaluation and Design Guidelines, published in 1997, focused on the ergonomic design of the bus operator workstation (43). According to the report, a number of operator injuries can result from poor design or vibration: CTDs, soft tissue in- juries, and musculoskeletal injuries. The study authors as- sert that to reduce the number of injuries the operator workstation should be ergonomically compatible with the range of physical dimensions and capabilities of operators. Areas addressed in this research included the design and location of the operator seat, steering assembly, pedals, farebox, radio, transfer tray, public address system, sun vi- sor, modesty panel, stanchions, controls, gauges, and other displays. After reviewing previous design efforts in bus operator workstations, conducting a task analysis of bus operators to define how they interact with the workstation, and con- ducting a survey to obtain recommendations from bus op- erators, the researchers prepared, constructed, and evalu- ated a mock-up workstation. The evaluation was conducted with 100 individuals—grouped according to stature and gender—on the basis of several factors, including visibil- ity, reach, and comfort. In addition, the researchers held workshops with representatives of bus manufacturers, workplace components manufacturers, and suppliers to get additional input on workstation design. Project outcomes include workstation design guidelines that present essential features that should be in a workstation: an 18-in. steering wheel, hanging pedals, and instrument panels divided into three areas according to function (43). Stress Management The personal costs of stress have been documented in a number of research studies. In one study, employees who participated in a stress management program took fewer sick days than nonparticipating coworkers. Those who re- ceived stress management assistance saw doctors 34% less often than their fellow employees who did not get assis- tance. One conclusion from the study was that a worksite program focusing on stress management, along with edu- cation for small groups, can reduce illness and the use of health care benefits. Teaching employees how to recognize stress reactions, and the dangers and damaging effects of stress, can be a powerful incentive for them to change their responses to the stress triggers in their lives. Practical tools that employees can use before, during, and after a poten- tially stressful situation can be particularly beneficial. Ex- perts emphasize that the best stress management programs are those that teach techniques that can be used on the job, such as deep-breathing exercises, guided imagery, and mu- sic therapy (12). Stress management programs offered at the time when employees are most tense can be very effective. For exam- ple, San Francisco Bay Area Rapid Transit (BART) pro- vided 1-day stress management workshops at a time when the system was stressed by an increase in the number of passen- gers. BART’s manager of performance and learning reported that breakdowns in aging equipment and incidents of workplace violence were increasing. Many employees re- sponded to the training by stating, for example, that “It was the best thing they had ever experienced at BART” (11). Experts caution that stress management programs have to be marketed so that they show a link to the bottom line. There is still a stigma attached to getting assistance for what are considered emotional disorders. Positioning stress management as a performance enhancement strategy and tracking results such as changes in productivity, absentee- ism, turnover, and adverse incidents can strengthen the credibility of stress management programs (9). Individuals in the stress management field also report that teaching employees self-management skills, and teaching supervi- sors and managers to reduce as many sources of stress as

16 possible, are two approaches found to be beneficial in re- ducing stress (11). Exercise Programs Research conducted by Principal Financial Group—a global financial institution—found that regular exercisers at the company’s on-site 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. The study compared an exercise group with employees in the nonexercise control group. Participants were classified as “exercisers” if they reported exercising at least 30 min, 5 or more days a week. “Nonexercisers” were those exer- cising once a week or less. Key findings of the study in- cluded the following: • Medical claims were considerably lower for exercis- ers versus nonexercisers. • Losses from absenteeism were lower for exercisers, who lost an average of 20.9 h compared with 36.6 h for nonexercisers (44). Data collected by researchers from worksite wellness programs throughout the nation used a combination of self- reported health risk assessment as well as blood pressure, weight, height, and blood chemistry profile data collected over a 2-year period. From a database of 4,751 women ages 17 to 72, 1,412 met requirements of being either an exerciser or nonexerciser from 30 to 59 years of age. This age range was selected because women in this age group are generally not viewed as having a high risk for heart disease and thus are overlooked (30). Overall, women who exercised showed more positive results than did nonexercisers in the following categories: • Less weight, • Lower BMI, • Lower blood pressure, • Lower-risk blood profiles (exception: the range of 40 to 49 years old for total cholesterol and LDL cholesterol), • Perception of their health and sense of well-being as being higher, • Higher level of energy to accomplish daily tasks, and • Fewer days of work missed. Exercise has long been associated with improved mood. In this study, exercisers reported healthier outlooks on life and an improved sense of well-being, indicating a poten- tially positive impact on women (30). Furthermore, exercise is highly recommended in any weight management program owing to its many benefits, including • Increased expenditure of energy, • Improved cardiovascular fitness, • Toned muscles, and • Improved sense of well-being (26). Drug-Free Workplaces Drug and alcohol policies implemented as a result of FTA regulations, which went into effect in 1995, have had a positive impact on the ability of transit agencies to have drug- and alcohol-free operators driving transit vehicles. Drugs tested for under the FTA regulations are marijuana, co- caine, amphetamines, opiates (morphine and codeine), and phencyclidine (known as PCP). In 2000, transit employers re- ported that a total of 249,733 employees were performing safety-sensitive functions, with 70% engaged in revenue vehi- cle operation. Of the 226,679 specimens collected for all types of drug testing, 3,583 tested positive for one or more drug type. The highest percentage was for reasonable suspicion testing, at 5.5%. The most frequently found drug was mari- juana, followed by cocaine. The most common combination of drugs was marijuana and cocaine. As with drug testing, the highest percentage of positive alcohol tests was for rea- sonable suspicion at 7.8%. Overall, from 1996 to 2000, the percentage of positive drug and alcohol test results decreased each year over the 5-year period, which may reflect the de- gree of the amount of attention that transit agencies have been giving to this health and safety issue (21). EAPs have played a major role in assisting employees with alcohol and drug dependencies rid themselves of these and other personal and work-related problems. In addition to being of benefit to employees and their fami- lies, EAPs provide a valuable adjunct to the employer’s benefit plan. For instance, a study conducted at Abbott Laboratories’ internal EAP found that employees with mental health problems and substance abuse diagnoses who received EAP services had significantly less in total inpatient and outpatient benefit costs than did those who did not receive EAP services (36). Key to the success of many EAP interventions is the employee’s willingness to voluntarily seek assistance. EAPs typically have a process by which a self- or family- referred employee can receive confidential assistance for a variety of work-impairing problems. Other services com- plementary to an EAP, such as work and family services and critical incident debriefings, are important for enhancing problem awareness and treatment (14). One strategy used successfully by the aviation industry, the Human Intervention Motivation Study (HIMS) pro- gram, relies heavily on peer intervention. In the early 1970s, HIMS grew out of a grant from the National Institute for Alcohol Abuse and Alcoholism. Results show that with

17 proper treatment for airline pilots, the pilot rehabilitation rate was successful (92% to 95%) and cost-effective. Pilots are assured that their treatment information is held in strictest confidence. In 2002, 1,415 pilots received treat- ment for alcoholism, and 79 for illicit drug dependence. According to the Aviation Medicine Advisory Service, of those participating in the HIMS program, the relapse rate was approximately 10% over a 3-year period (45). Smoke-Free Workplaces Workplaces nationwide are going smoke free. According to a Gallup poll, 95% of Americans, smokers and nonsmok- ers, now believe companies should either ban smoking to- tally in the workplace or restrict it to separately ventilated areas (18). In 1999, nearly 70% of the U.S. work force worked under a smoke-free policy. A 1998 study by the National Cancer Institute found that 65% of the employees who responded reported that their workplaces banned smoking. This percentage is up from 47% in 1993 (17). Disease Management Employers are increasingly turning to 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 employees, boost pro- ductivity, and reduce medical insurance premiums. Accord- ing to the Pharmacy Benefit Management Institute, in 2001, 44% of employees offered DM for chronic medical conditions, up from 14% in 1995 (46,47). Asthma, diabetes, and cardiovascular disease are the three major illnesses most commonly addressed by DM programs. The goal of DM is to ensure that employees re- ceive the best care possible and avoid complications. DM involves employees in their care, ensures proper treatment by physicians, and helps to make sense of medical infor- mation. Often a contracted service, many DM programs focus not only on cutting health care costs, but also im- proving employee attendance and ability to contribute at work. DM programs encourage employees to sign up with a provider that educates them about their diseases—how to manage them and the importance of proper medical care. Also, DM programs hold down costs by providing em- ployees and their caregivers with information on how to monitor and treat conditions and coordinate communica- tion among the various stakeholders in the employee’s health care coverage (46,47). The most effective DM programs are those that are rela- tively inexpensive to manage or that would otherwise re- quire high-cost treatment, such as surgery or emergency room visits. Because comprehensive DM programs can be expensive, many employers target their programs based on insurance claims and prescription plan data. Elements in an effective DM program include the following: • Educational mailings to employees; • Access to nurses who provide information and track progress; and • Information systems that keep track of patient data, care plans, and outcomes (45). Self-care and education efforts that focus on helping the employee understand his or her illness and treatment are important aspects of effective DM programs. Such pro- grams are sometimes separated into three categories of service: high-risk individuals who receive frequent tele- phone calls, as well as home visits or medical monitoring; medium-risk individuals who require frequent telephone contact; and low-risk individuals who can get by with fre- quent mailings and occasional telephone contact (47). Massage Therapy: Example of a Complementary Health Initiative Health and wellness programs now include a number of complementary or alternative health approaches in their of- ferings. For instance, massage therapy has become a part of many programs. In some cases, employees pay the cost, which is frequently a 10- to 15-min chair massage. A num- ber of advantages are cited for offering massage. • Reduces stress-related illness, • Reduces direct and indirect health maintenance costs, • Reduces workers’ compensation and disability insur- ance payments, • Reduces absenteeism, and • Requires no capital investment to initiate or no over- head to maintain (48). One study found that adults who received two 15-min massages weekly showed signs of marked relaxation and increased speed in completing mathematical computation than peers who did not have massages. Those receiving massages also reported less depression and reduced anxi- ety. Having massage therapists come to the worksite moti- vates employees who do not have time to take off for re- laxation to receive therapy at a time convenient to them. Employers offering massages reported that often all avail- able appointments are filled each time the massage thera- pist is scheduled (48). EMPLOYEE EMPOWERMENT Two examples of employee empowerment illustrate the role that employees without formal preparation as health and wellness specialists can take to improve their health

18 and well-being in the workplace. The first looks at the en- hancement of the role of natural employee helpers, people to whom others turn to “naturally” for information, support, and guidance. This inclination is the basis for a model that uses lay people to coordinate worksite health promotion pro- grams. The Natural Helper model of social change identifies these people and strengthens their role and existing networks through education and resources. In one project, researchers recruited and trained more than 100 natural helpers in 4 work- places in rural locations in North Carolina (49). The goal was to develop a workplace wellness program for small- to medium-sized workplaces or manufacturing workplaces to accomplish the following eight objectives: 1. Address employee interests and barriers to behavior change; 2. Empower and teach new information and skills; 3. Have interesting and fun activities; 4. Have theory-based activities with a strong evaluation component; 5. Be flexible and possibly adapted for many health behaviors; 6. Be able to be used alone or with other health promo- tion programs; 7. Be able to be implemented without disrupting pro- duction schedules; and 8. Be affordable and possibly implemented without a large investment of staff time, resources, or reliance on health professionals. The program evaluation revealed that the natural help- ers did indeed spread the word about fitness, nutrition, and cancer prevention to coworkers, and they provided support to employees who wanted to make behavior changes. These helpers also initiated workplace changes by starting walking groups, making changes in vending machine se- lections, and sharing healthful lunches (49). A second example of employee empowerment involved 345 employees at three locations of the Puritan–Bennett Corporation, a leading producer of ventilator systems, oxygen therapy, sleep diagnostics, and other respiratory products. A team of employees embarked on a pilot 3-year employee-driven health and wellness program, Perfect Health, in which they used a health risk appraisal instru- ment and health screening to establish baseline data by which to measure employee health risks. The Perfect Health Council, a volunteer group of employees, designed and implemented the program. That group represented em- ployees on issues related to health and safety at work and home. Employees joined one of four subcouncils to address specific issues: promotion, health education, fit- ness and recreation, and safety and environment. Promo- tion workers marketed all events. Health education work- ers sponsored events such as lunchtime lectures, nutrition planning, and a newsletter. Similarly, fitness and recreation workers sponsored sports leagues, tournaments, and fitness clubs. Also, safety and environment workers sponsored a seat-belt awareness campaign, lectures, and recycling pro- grams. The program included a year-round incentive pro- gram in which participating employees could earn prizes and up to $150 toward payment of costs of off-site health promotion activities each year. However, the study had some limitations. For example, because participation was voluntary, the issue of a biased sample of employees arises; that is, these employees may have been more interested in their health and well-being than the general population. Even so, data from this effort suggest that participation in the program may have modified participants’ behaviors as- sociated with the risk for death from both heart attack and lung cancer. Strengths included employee involvement in designing and implementing the program, support from executive management from its inception, and incentives to encourage and maintain employee health and wellness programs (50).

19 CHAPTER THREE SYNTHESIS SURVEY RESULTS SUMMARY OF AGENCIES SURVEYED A critical element of this synthesis was the survey, which gathered data from transit agencies on their current prac- tices related to transit operator health and wellness pro- grams. To get a representative sample, more than 50 tele- phone calls were made to transit agencies of various sizes, modes of operation, and geographic locations. In addition, the consultant made use of contacts established while con- ducting other TCRP studies. Ultimately, the survey was sent to 33 transit agencies. Follow-up calls were made to agencies that did not respond. A total of 16 agencies re- sponded; however, 2 respondents indicated that their pro- grams were in preliminary stages of development and therefore were not able to provide enough substantive data to be used in this study. Responding agencies ranged from two of the largest in the nation to medium and small agen- cies in each region of the nation. A roster of the 14 agen- cies is provided in Appendix B. DESCRIPTION OF SURVEY RESULTS This section outlines the results of the survey and discusses responses to each category of questions. The first part of the survey requested general background information to provide a sense of the types of organizational structures and operations represented in the survey sample. Most sur- vey respondents were employed in special transit authori- ties or districts. Two indicated that their organization is a city or county agency. One responded that its agency is a joint-powers agency. Agencies ranged in size from one with 10,056 bus op- erators and 3,384 rail operators to one with a total of 83 bus operators. Six of the agencies employ bus and rail operators. Operator work forces are predominantly male, ranging from 50% to 89%. Operators are ethnically di- verse, with the percentage reported by responding agencies differing from locale to locale. Of the 10 agencies that pro- vided data on the ethnic backgrounds of operators, seven reported that more than 50% of are minorities, ranging from 53% to 76%. In the 10 agencies, operators of Afri- can–American descent make up the largest minority group, followed by Hispanics. The length of time that health and wellness programs have been in place ranges from 2 to 14 years. Nine agencies locate the health and wellness pro- gram in HR, with two in medical/occupational health, two in safety, and one in finance. As shown in Figure 1, agencies reported a variety of health risk factors. Health risk factors are those circum- stances or conditions that can predispose a person to seri- ous health problems. Lack of physical activity (10 agen- cies), uncontrolled hypertension (9), obesity (9), and unhealthful diet (9) top the list of factors contributing to health and wellness problems for transit operators. Other risk factors frequently mentioned were stress and uncon- trolled diabetes, each mentioned six times. Less frequently identified risk factors are smoking (3), drug and alcohol use (2), high cholesterol (1), and fatigue (1). Allocation of Resources A common approach to worksite health and wellness pro- gram design is to allocate resources to three categories of activities: (1) awareness activities that encourage healthful lifestyle changes, (2) education that teaches employees how to make changes to reduce risk factors or address specific condi- tions, and (3) behavior changes that focus on giving employ- ees the tools and support needed to improve health and well- ness for the long term. Several respondents were able to identify how they allocated program resources. The results vary in the following ways: three agencies reported that they allocated 33% of resources to each category; six agencies re- ported that they allocated the majority of resources, between 60% and 80%, to the awareness category; and one agency re- ported allocation of the largest amount of resources (40%) to behavior change activities. Others, especially those where programs were part of other organizational units such as EAP, were not able to identify specific percentages of re- sources allocated to the three categories. One of the challenges that health and wellness program leaders encounter is how to link program goals with organiza- tional business results. Transit health and wellness programs reported that they collect and analyze supporting data from a variety of sources. The largest number of agencies reported collecting data from workers’ compensation claims and costs (10 agencies), followed by ergonomic analysis and EAP utili- zation reports (9 each). The next most frequent response was eight agencies reporting on the use of each of the following: passenger-related incident reports, passenger satisfaction surveys, health screenings, health care claims, and disabil- ity claims. Cited to a lesser extent were programs to collect and analyze employee demographic data (7 agencies) and turnover records and fitness-for-duty assessments (6 each). These results are shown in Figure 2.

20 0 2 4 6 8 10 12 14 Number of Transit Agencies Reporting Fatigue High Cholesterol Drug and Alcohol Use Poor Back Care Smoking Stress Uncontrolled Diabetes Obesity Uncontrolled Hypertension Unhealthy Diet Lack of Physical Activity FIGURE 1 Primary health risk factors. 0 2 4 6 8 10 12 1 Fitness-for-duty assessments Turnover records Demographic information Disability claims Health care claims Health screening Passenger satisfaction surveys Passenger-related incident reports EAP Utilization Ergonomic analysis Worker compensation costs/claims Number of Transit Agencies Reporting 4 FIGURE 2 Data collection and analysis. Reasons for Starting Health and Wellness Programs The survey revealed that transit agencies started health and wellness programs for a number of reasons. Respondents were given the option of selecting from among nine stated reasons, with the option to identify reasons other than those listed on the survey. More than one response could be selected. The most frequently selected reasons for start- ing health and wellness programs were to reduce health care costs (11 agencies), reduce absenteeism (10), reduce occupational injury (8), enhance productivity (8), improve morale (7), and respond to operator requests (5).

21 Fitness-for-Duty Evaluations Eleven agencies answered the question “Are fitness-for- duty evaluations included in the operator health and well- ness program? If so, how and when are they conducted and how and where are records kept regarding outcomes of these evaluations?” Most of those responding (7), reported that fitness-for-duty examinations are conducted in organizational units other than the health and wellness program. Four agencies conduct the examinations as part of the health and wellness program. In three instances, records are kept in HR and one in another department. Budget Budget data for health and wellness programs often were not provided by survey respondents. However, from those agencies responding, budget allocations for health and wellness programs showed broad variations, some of which might be the result of the size of the organization as well as from other organizational nuances. Some programs are budgeted as part of other programs and respondents do not have access to accurate data. In two cases, economic downturns in their regions resulted in vast budget reduc- tions over previous years. In another case, the program is coordinated in large part by employee volunteers; there- fore, the budget allocation is quite small. It is clear that budget allocation responses in some cases did not include employee compensation costs. Program Participation Rates Twelve agencies reported on participation rates in health and wellness programs over the past 2 years. They noted that participation has increased substantially (6 agencies), remained about the same (5), or increased modestly (1). Management and Union Support Although formal health and wellness programs have ex- isted in other industries for many years, they are still not the norm in the transit industry. Table 1 shows the strongest management support in three areas: managers actively promote participation in health and wellness activities (10 agencies), have allocated adequate resources (10), and have appointed individuals to lead the health and wellness program (10). Six agencies responded that the CEO has communicated the importance of the health and wellness program through such mechanisms as for- mal memos and bulletins, employee orientation presenta- tions, and public addresses. In four cases, a specific indi- vidual was hired to lead the program, whereas in four other cases a committee to lead or support the program was ap- pointed. Three agencies included language in their organ- izational vision or mission statements about employee health and wellness. Of the 14 agencies responding, 7 (50%) reported that unions support health and wellness activities by proposing health and wellness provisions during collective bargaining (Table 2). In five cases, union leaders have signed off on joint labor–management documents encouraging participation in health and wellness activities. In three agencies, union leaders regularly participate in these activities. Similarly, in three agencies, union leaders communicate the importance of health and wellness to members through vehicles such as written bulletins, newsletters, or public addresses. Health and Wellness Team Broad-based involvement by representatives of various employee constituencies helps to ensure that the health and wellness program is appropriately linked with other organ- izational priorities. Such involvement can also increase the sense of ownership for the quality and viability of the pro- gram throughout the organization. The teams assigned re- sponsibility for health and wellness activities vary among agencies. As shown in Table 3, in nine agencies health and wellness information is integrated into orientation and/or training programs(s) for new operators. In nine agencies, activities are coordinated with the EAP. An equal number of agencies (7) reported that health and wellness activities are coordinated with employee benefits, workers’ compen- sation, and safety programs. Three agencies reported coor- dination with the drug and alcohol testing program and two coordinate with food services. TABLE 1 MANAGEMENT SUPPORT FOR HEALTH AND WELLNESS PROGRAMS Methods by Which Management Demonstrates Support No. of Agencies Managers actively promote participation in health and wellness activities 10 Management allocates adequate resources 10 Individual(s) appointed to lead program 10 CEO communicates importance of employee health and wellness 6 Employee hired to lead program 4 Committee appointed to lead or support program 4 Health and wellness statement in agency mission/vision statements 3

22 TABLE 2 UNION SUPPORT FOR HEALTH AND WELLNESS PROGRAMS Methods by Which Unions Demonstrate Support No. of Agencies Union leaders propose health and wellness provisions during collective bargaining 7 Union leaders signed off on joint labor–management documents encouraging participation 5 Union leaders regularly participate in health and wellness activities 3 Union leaders communicate support to members 3 TABLE 3 HEALTH AND WELLNESS TEAM Team Characteristics No. of Agencies Health and wellness information integrated in new operator orientation and/or training programs 9 Health and wellness activities coordinated with EAP 9 Health and wellness activities coordinated with employee benefit program 7 Health and wellness activities coordinated with workers’ compensation program 7 Health and wellness activities coordinated with safety programs 7 Committee members serve as health and wellness advocates at worksites 6 Committee developed mission statement, priorities, defined roles and responsibilities 5 Committee with membership other than in positions as listed meets regularly 4 Health and wellness committee that includes operators, union leaders, managers, and representatives of other departments meets regularly 4 Health and wellness activities coordinated with drug and alcohol testing program 3 Proceedings of committee meetings communicated to operators and managers 3 Health and wellness activities coordinated with food services 2 In six agencies, health and wellness committee mem- bers serve as health and wellness advocates at worksites. Committees in five agencies have developed mission state- ments, priorities, and defined roles and responsibilities for members. In four agencies, committees that include operators, union leaders, managers, and representatives of other depart- ments meet regularly. Committees in four agencies with other mixes of representatives reported that they also meet regu- larly. Three agencies communicate the proceedings of com- mittee meetings to both operators and managers. Program Communication Effective health and wellness programs include a clear communication plan by which to keep target audiences in- formed of program activities and results. Regular and visi- ble communication can also serve as a motivator for em- ployees who have not yet made a decision to make health- ful lifestyle changes. Regular communication can also keep the program in the forefront of senior management at- tention. Health and wellness programs use a variety of communication’s strategies to keep operators and man- agement informed. Figure 3 shows responses related to program communication. Reminders are supplements to in- formation sent earlier to employees about program activi- ties or their commitments. Changes refer to notices of any changes in policy or benefit options. Updates keep em- ployees informed of program activities and may be in the form of progress reports. Formal mechanisms include es- tablished communication tools such as suggestion boxes, e-mail messages, or surveys that allow employees to pro- vide feedback and input to wellness staff. Information re- lated to the community refers to giving employees infor- mation provided by community agencies about services they provide. Operator input about line activities refers to operators being encouraged to participate in ongoing dia- logue about activities such as work assignments and schedule design, and accident and incident prevention. Timely feedback refers to whether operators receive timely feedback about whether and how their input is used. Annual Operating Plan A well-designed annual operating plan can serve a number of purposes. Having to prepare the plan makes those ac- countable for the program define program priorities and how these priorities are expected to contribute to employee health and well-being. Clear mission and vision statements, as well as goals, objectives, and tactics can provide a road map for how the program will achieve planned activities. Being able to communicate details of the annual plan with employees can provide a sense of program stability and create a sense of excitement among employees about up- coming activities. The operating plan can also communi- cate to employees that their health and well-being are a priority of the organization. Agencies reported the following about annual operating plans for health and wellness programs: eight have pre- pared an operating plan that addresses the needs and inter- ests of operators, linked program goals and objectives with strategic organizational priorities, and specified time lines for when activities and tasks are to be completed. Seven agencies reported having a budget sufficient to carry out

23 0 2 4 6 8 10 12 1 Number of Transit Agencies Reporting Timely feedback Operator input/line Information/Community Formal mechanisms Updates Changes Reminders 4 FIGURE 3 Communication strategies. 0 2 4 6 8 10 12 14 Number of Transit Agencies Reporting Evaluation Responsibilities Goals Marketing Budget Timelines Linkages Plan FIGURE 4 Annual operating plan. the plan, and seven that they have incorporated appropriate marketing strategies to effectively promote and communi- cate programs to operators. Six agencies reported having established clear, measurable goals and objectives and six assigned specific responsibilities for the completion of plan tasks. Four agencies have developed a plan for evaluating the accomplishment of goals and objectives. These results are illustrated in Figure 4.

24 TABLE 4 ORGANIZATIONAL ENVIRONMENT Environmental Factors No. of Agencies Assistance with work/life balance 10 Monitoring of facility lighting, heating, ventilation, and overall safety 10 Promotion of disability prevention and management 9 Recognition and rewarding of operator successes 8 Accessible health and wellness library 8 Peer support and mentoring activities 7 Incentives for participation 7 Vehicles maintained in ergonomically sound condition 6 Healthful food options/vending machines/cafeteria 6 Reimbursement for health club/health activities 1 Release time for health and wellness activities 1 0 2 4 6 8 10 12 14 Number of Transit Agencies Reporting Reimburse/fee based Comp time Flex time Child care Job training Disability FSA LOA Tuition Life insurance SL/well days EAP Health Insurance Retirement Vacation FIGURE 5 Benefit options. EAP = employee assistance programs; SL = sick leave; LOA = leave of absence; FSA = flexible spending account. Organizational Environment The success of health and wellness programs is in large part a product of the overall organizational environment. Workplaces in which employee health and well-being are seen as organizational assets tend to have tangible and visible evidence that employees are valued. Transit agen- cies with a commitment to having a healthy work force implement strategies designed to make such a work force a reality. A health and wellness program is one initiative seen more commonly in such organizations. As Table 4 shows, diverse activities among the responding transit agencies support a healthy work environment. Ten agen- cies provide assistance with work–life balance and 10 also reported processes for maintaining a healthy work envi- ronment through monitoring facility heating, lighting, ven- tilation, and overall safety. Nine agencies reported that their organizations promote responsible disability preven- tion and management through programs such as early re- turn to work and restricted duty assignments. Other sup- ports provided included an accessible health and wellness library (8) and recognition of operator successes (8). One- half of the agencies (7) provide peer support and mentoring opportunities as well as incentives for participating in health and wellness activities. Six agencies ensure that transit vehicles are maintained in ergonomically sound

25 0 2 4 6 8 10 12 14 Number of Transit Agencies Reporting Healthy food Tobacco restrictions Smoke free Emergency procedures Seatbelt/safe driving Alcohol/drug condition and that healthful food options are available in vending machines and/or cafeterias. Figure 5 provides a view of how another aspect of or- ganizational support, employee benefits, is represented in re- sponding agencies. All agencies reported offering health in- surance, vacation, retirement, and EAP benefits. Thirteen also offer life insurance and sick leave coverage. Twelve agencies allow leaves of absence and make tuition reimbursement available. Ten agencies provide disability coverage and flexi- ble spending accounts. One-half (7) provide job training or re- imbursement, while five offer child care assistance. Benefits such as compensatory time and flex time are offered by three agencies. Two agencies provide reimbursement for fee-based health and wellness program activities. A third view of a supportive organizational environment is shown by policies that are complementary to health and wellness efforts. Figure 6 shows the types and frequency of policies that fall into that category. All 14 agencies reported having drug and alcohol polices, while 13 reported having policies related to emergency procedures and seat belt use and safe driving. Ten agencies have smoke-free work envi- ronment policies. Two agencies responded that they have policies on the availability of healthful food options. Program Activities The survey requested information on the types of health and wellness activities that each transit agency offers and in what format these activities are offered. Agencies were given six activity formats from which to select: health in- formation, group education, self-study, computer-based/ Internet/intranet, individual counseling, and ongoing be- havior change. The survey listed 20 activity options (e.g., physical activity, smoking cessation, disease management, and fatigue awareness) from which agencies could select; they could add others as needed. For each activity, the agency was asked which formats are used; more than one format per activity could be selected. Figure 7 shows the number of times that each format was used for the list of program activities selected. The health information format was selected 141 times, group education 77, individual counseling 36, and behavior change 21. Selected least fre- quently were computer-based (17) and self-study (15) for- mats. These responses are consistent with responses given to the earlier survey question about resource allocations to three categories of health and wellness activities: aware- ness, education, and behavior change. Awareness-focused activities in responding agencies far outrank those activi- ties in other categories. The health information format tends to be very useful when the program focus is on creating awareness. This format is used most frequently to give information about stress management (10 agencies), with nine agencies re- porting on the use of this format to impart information about weight management, nutrition, and disease manage- ment. More than one-half of the respondents (8) use the health information format to create awareness about re- sponsible alcohol use, mental health, ergonomics, and car- FIGURE 6 Policies supportive of health and wellness programs.

26 0 10 20 30 40 50 60 70 80 90 100 110 120 130 140 150 Number of Transit Agencies Reporting Self Study Computer Based Behavior change Individual counseling Group Education Health Information FIGURE 7 Activity formats by frequency of use. diovascular disease prevention. One-half reported using this format to provide information about smoking cessa- tion, physical activity, medical self-care, flu shots, and fa- tigue awareness. Group education, which focuses on teaching employees how to make changes to reduce risk factors or to address specific conditions, is used most frequently to teach about disease management (8 agencies), weight management (7), and nutrition (6). Five agencies reported using group edu- cation to teach employees about smoking cessation, stress management, flu shots, ergonomics, and fatigue awareness. In addition to group education, individual counseling is an alternative that can be used to teach employees about how to make health behavior changes. Depending on an employee’s readiness for change, counseling can also be a tool for the employee to make the transition to behavior change and for supporting him or her through the period of transition. Although cited by only a small number of re- spondents, counseling is used to address specific health risks and issues. The ultimate goal in worksite health and wellness pro- grams is to help employees develop healthful work and lifestyle practices that they can sustain over time. In many cases, once employees are aware of the need for change and they have received appropriate education on how to make the changes, behavior change becomes more likely. This behavior change format is typically more intensive than the others and in many cases it requires a longer-term commitment on the part of the employee and the health and wellness professional. Responding agencies tend to devote very little attention to the behavior change format. Three agencies reported using behavior change to address physical activity, nutrition, and weight management, while two reported using it for smoking cessation, cardiovascular disease prevention, and DM. To get a snapshot of which activities receive the most attention in health and wellness programs, an analysis was performed to determine the activities most frequently of- fered through all formats. Figure 8 shows the results of that analysis. DM (25), weight management (24), nutrition (22), stress management (20), and mental health care (20) are the most frequent activities. This list of activities was followed closely by ergonomics (19), flu shots (19), smok- ing cessation (18), cardiovascular disease prevention (18), and physical activity (17). This analysis suggests that tran- sit agencies are focusing on risk factors that are most rele- vant to their target populations. The review of literature and survey results indicate that each of the aforementioned frequencies make good business sense. The survey requested information from a list of 18 ac- tivities often included in worksite health and wellness pro- grams about whether transit agencies offered certain activi- ties or used various resources. Figure 9 shows the frequency with which the most often used activities were selected. Each of the 14 agencies reported using wellness

27 0 5 10 15 20 25 Number of Transit Agencies Reporting Responsible alcohol use Fatigue awareness Physical activity Cardiovascular disease prevention Smoking cessation Ergonomics Flu shots Mental health Stress management Nutrition Weight management Disease management 0 2 4 6 8 10 12 14 Number of Transit Agencies Reporting Walk/run clubs Alternative health Lactation Meditation/nap Challenges Exercise classes Walk/run paths Bike storage facilities Community events Blood drives Onsite fitness facilities Lockers/show ers Health fairs ellness brochure/poster displays W FIGURE 8 Activities most frequently offered through health and wellness formats. FIGURE 9 Frequency of health and wellness activities and resources. brochures, poster displays, and health fairs. Twelve agen- cies provide showers and/or lockers for program partici- pants. Eleven agencies participate in blood drives and an equal number offer on-site fitness facilities. Nine agencies provide bike storage facilities, and nine participate in community events such as runs, walk-a-thons, and bicy- cling. One-half of the agencies (7) provide walking or running paths for employees, 6 offer exercise classes, and

28 6 offer health and wellness competitions or challenges. Fewer agencies offer such options as meditation or nap rooms (5), lactation rooms for new mothers (4), alternative health approaches (4), and walking or running clubs (3). Program Evaluation A solid program evaluation is critical to the survival of any organizationally supported program. Transit agency health and wellness program leaders must be able to show that public funds are being used in a way that contributes to the bottom line of the organization. Typically, program evalua- tion is tied to program mission, goals, and objectives. Table 5 outlines the types of program evaluation methods used to measure the achievement of health and wellness program goals. Eleven (79%) of respondents stated that they track employee participation in program activities, a key meas- ure of employee interest. Other evaluation measures in- clude monitoring employee satisfaction (6 agencies); as- sessment of changes in biometric measures such as body weight, strength, flexibility, cholesterol levels, and blood pressure (6); and assessment and monitoring health status of high-risk operators (6). Fewer agencies analyze cost- effectiveness, savings, and return on investment (5); moni- tor the impact of productivity indicators such as absentee- ism, turnover, and morale on the health and wellness of operators (4); and measure changes in cultural and physical environments such as policy, benefits, and changes in working condition (3). One agency reported documenting improvements in operator knowledge, attitudes, skills, and behaviors as a program evaluation activity. TABLE 5 PROGRAM EVALUATION Evaluation Activities No. of Agencies Regularly track participation 11 Monitor participant satisfaction 6 Assess changes in measures 6 Assess and monitor high-risk operators 6 Analyze cost-effectiveness, savings, and return on investment 5 Monitor key productivity indicators 4 Measure changes in cultural and physical environment 3 Document improvements in knowledge, attitudes, skills, and behaviors 1