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

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15 3.1 Introduction The literature review conducted for this study builds on past studies, including TCRP Report 169: Developing Best-Practice Guidelines for Improving Bus Operator Health and Retention and TCRP Report 174: Improving Safety Culture in Public Transportation (Gillespie, Wang, and Brown 2014; Roberts, Retting, and Webb et al. 2015). A large and varied body of literature was reviewed on factors affecting transit workers, their health conditions, health costs, and approaches by agencies to implement health prevention, health promotion, and safety programs. This chapter provides an overview of workforce conditions and health and safety outcomes for transit workers, reviews programs designed to mitigate negative health and safety outcomes, and summarizes the cost-effectiveness of health and safety intervention programs known to date. This study focuses on the conditions of the work environment that impact transit operations and maintenance personnel. In this literature review, the project team examined the following topics: • Workforce conditions: health and safety outcomes, • Workforce conditions: costs, • Programs to mitigate negative health and safety outcomes, and • Cost-effectiveness of health and safety intervention programs. Work conditions for public transit workers bring several unique health-related challenges and safety concerns, for which the associated costs are borne by workers, workers’ unions, employers, the government, and the public. Some conditions in the public transit work environment constrain healthy behavior and may result in negative health and safety outcomes. The project team reviewed research on related circumstances and challenges: • Behaviors and conditions that affect health and safety (e.g., sedentary nature of the job, sleep deprivation, exercise, diet, smoking, alcohol use); • Chronic diseases (e.g., diabetes, cardiovascular disease, musculoskeletal disease); • Communicable diseases; • Labor environment; • Organizational issues (e.g., safety climate, organizational programs, policies and procedures, support at work); • Organization of work (e.g., shift work, job discretion, job demands); and • Access to health-promoting activities and healthcare. 3.2 Workforce Conditions: Health and Safety Outcomes Vehicle operators face specific challenges in the workplace due to their long shifts and expo- sure to vehicle and road vibrations. Musculoskeletal injuries can result from a combination of uncomfortable seating and non-optional operator behavior. Research has shown that the C H A P T E R 3 Literature Review and Baseline Data

16 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line repetitive action of turning the steering wheel of a bus can lead to back problems (Anderson 1992). Bus drivers were shown to exhibit pain at a rate at least one-third higher than that of the general population, with the author concluding that the higher prevalence of spinal problems can be attributed to stresses associated with turning to the left while driving and to the right while loading and unloading passengers. Because vehicle operators often work odd hours and work offsite (i.e., in conditions that may lack the amenities and supports available at a central or fixed workplace), they may suffer from fatigue and high levels of stress. Inadequate access to restrooms exacerbates worker stress and fatigue. In Washington, D.C., Metro stations have restrooms, but the facilities are sometimes inaccessible due to issues of cleanliness caused by use by the public (Brown 2012). The lack of adequate facilities can increase delays, cause low worker morale, and lead to higher operator turnover rates. Metro Transit in Minneapolis, Minnesota, addressed this by having restrooms in stations and nego- tiating contracts with convenience stores and gas stations along bus routes to allow transit operators to use their facilities (Brown 2012). In addition to chronic conditions and health risks, transit workers face several safety chal- lenges. As discussed in TCRP Report 174, many transit agencies are trying to improve their safety culture (Roberts, Retting, and Webb et al. 2015). Safety concerns include unruly or aggressive passengers, other driver and pedestrian error, and the risk of accidents due to fatigue from long, irregular, or split shifts or to fatigue associated with health conditions such as sleep apnea (Petrie 2014). A report on the causes of bus crashes in New Jersey (a state with a large number of transit services) found that more than one-third of bus crashes (15 out of 40 crashes from 2005 to 2006) were attributed to driver inattention or inadequate surveillance of traffic and pedestrians (U.S. DOT 2010). Evidence suggests that the mental and physical stresses of long hours spent in a vehicle can have cumulative health effects. In a 2012 survey of workers in various occupations, transpor- tation workers reported the highest rates of chronic health problems and the lowest well- being (Witters 2013). Various studies have documented that transit workers suffer from back problems and pain, cancer (lung, stomach, and rectal), diabetes, and hearing loss at higher rates than the general population (Hansen, Raaschou-Nielsen, and Olsen 1998; Morikawa, Nakagawa, and Ishizaki et al. 1997; Centre for Exploitation of Science and Technology 1993; Gubéran, Usel, and Raymond et al. 1992; Siemiatycki, Gerin, and Stewart et al. 1988). The NIOSH tracks safety for more than 7 million workers in the transportation, warehousing, and utilities sector, which includes public transit workers. Workers in these industries are dis- proportionately at risk of vehicular accidents and exposure to emissions, as well as environ- mental and occupational hazards such as electrocution, overexertion, and falls. Irregular shifts or long-term overnight work and daytime sleep have a negative impact on rest and awareness, which can create a higher risk of crashes. Between 2003 and 2006, workers in the transportation, warehousing, and utilities sector—particularly truck drivers—made up 15% of workplace fatali- ties, but only comprised 5% of the U.S. workforce (CDC 2014). In 2006, costs related to fatal occupational injuries to transit and ground transportation workers were estimated at more than $200 million per year (CDC 2014). Workers in the transit and ground transportation industry are disproportionately at risk of exposure to emissions (CDC 2014). In 2010, an estimated 13.9% of transportation workers were exposed to secondhand smoking, and an estimated 40.4% were exposed to noxious fumes and vapors (CDC 2013b). Compared to all U.S. workers, transit and ground transportation workers are twice as likely to be exposed to hazards from outdoor work and one and one-half times as likely to be exposed to vapors, gas, dust, and fumes (CDC 2013b). Such environ- mental exposures are associated with an increased risk for developing various types of cancer Health and Safety Issues Faced by Transit Workers: • Stress related to long, irregular, and split shifts; • Lack of access to nutritious food; • Lack of regular access to restroom facilities; • Repetitive-motion musculo- skeletal injuries; and • Sleep disorders.

Literature Review and Baseline Data 17 (e.g., lung cancer, mesothelioma). For the 18.1 million people projected to survive cancer in 2020, the cost of their cancer care has been estimated at $8,716 per survivor, or $157.77 billion in 2010 dollars (Mariotto, Yabroff, Shao, Feuer, and Brown 2011). It is important to note that chronic conditions, health risks, and safety risks can have bidirectional effects: Poor health may exacerbate driver distraction and increase the risk of a work-related injury; likewise, work-related injuries may exacerbate or increase the risk of chronic conditions. 3.3 Workforce Conditions: Costs Chronic illnesses such as hearing loss, diabetes, and some cancers can carry large medical and economic costs: People who have been diagnosed with diabetes, for example, incur an esti- mated average of $7,900 per year in diabetes-related medical expenditures (American Diabetes Association 2013). Depending on the type of cancer, treatment protocol, insurance agreements, and other factors, a patient’s direct medical costs associated with long-term cancer treatment can range from hundreds of dollars to thousands of dollars per month (Yabroff, Lund, Kepka, and Mariotto 2011). A review of health findings for bus drivers revealed various conditions and issues, including the following (Tse, Flin, and Mearns 2006): • Physical conditions (cardiovascular disease, gastrointestinal disorders, musculoskeletal disorders, fatigue); • Psychological conditions (depression, anxiety); • Risky behaviors (alcohol use, smoking); and • Productivity losses (absenteeism, turnover, accidents). Studies have shown a high prevalence of health risk factors such as obesity and smoking among transit workers. The highest age-adjusted prevalence of obesity (i.e., a body mass index[BMI] ≥ 30) from 2008 to 2011 was found in transportation and material moving workers, especially motor vehicle operators, ranging from 36.5% for White women to 73.9% for Black women, and from 36.5% for White men to 39.6% for Hispanic men (Gu, Charles, and Bang et al. 2014). Cunradi, Lipton, and Banerjee (2007) found that, over 10 years, 22.6% (N = 1,016) of San Francisco railway transit operators had initiated, increased, or maintained smoking. Findings from a sub sample of this population (n = 654) showed that the odds of initiating, increasing, or maintaining smoking were increased for Black operators and operators with job-related stress (Cunradi, Lipton, and Banerjee 2007). Costs related to fatal occupational injuries in transit and ground transportation workers were estimated to amount to more than $200 million per year in 2006 (CDC 2014). According to the Motor Carrier Safety Progress Report, the number of bus crashes from January through December 2017 was 16,931, and the number of bus injuries was 18,105 (FMCSA 2018). In 2013, the costs to employers for on-the-job non-fatal injuries amounted to $64,981 for each employee injured, whereas the estimated costs to employers of on-the-job crashes of local and interurban transportation vehicles were $2,272 per employee (Network of Employers for Traffic Safety n.d.). Injuries and the development of chronic illness in transit workers can create large economic losses from reduced workdays, shortened career spans, and the costs of clinical care. These costs accrue to the government in the form of paying for replacement workers when transit workers call in sick. As illustrated in Table 1, public transit workers have three times higher rates of nonfatal occupational injuries and illnesses than workers in all industries. As seen in the table, urban transit workers experience 4.9 cases of illness with days away from work, job

18 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line transfer, or restriction per year per 100 full-time workers, compared to 1.7 cases for workers in all industries. Estimates for lost days for those who exited the industry for health reasons could not be included in Table 1 because the research used cross-sectional data. Panel data that focused specifically on transit workers, which might have allowed for such an analysis, was unavailable. Although many public transit workers who become sick or are injured on the job receive workers’ compensation, only the most egregious health issues may be compensated through workers’ compensation. Public transit workers may be sufficiently sick or disabled that they can no longer operate a vehicle but not qualify to receive workers’ compensation benefits or social security income, and they may not yet qualify for a pension. Health problems also can result in lower wages for public transit workers due to associated declines in performance or time spent out of the labor force. People who face the most common health issues that affect public transit workers also may have a shortened life span compared to the general public. Given these effects, improvements in work conditions may offer multiple benefits to drivers, including a reduction in chronic health problems, increased earnings, and improvements in the length or long-term quality of life. Direct costs to society of public transit worker health and safety issues include lower quality service (e.g., delays), the costs of healthcare provided to public transit workers through public insurance programs, and the costs of accidents that can be at least partially attributed to transit worker health problems. Indirect or secondary impacts of improved transit worker health include reducing the costs to society. Transit service quality may improve if a system is better able to retain experienced operators. Reductions in absenteeism may contribute to more consistent and better service to the public, and workers in better health may operate transit vehicles more safely. In areas where rapid transit is of high quality, rents and property values could increase, as could the availability of investment dollars or financing for development. 3.4 Programs to Mitigate Negative Health and Safety Outcomes Research on workplace wellness and safety interventions is still relatively new, and the find- ings are mixed. Many workplaces have wellness programs that are not well supported, funded, or targeted to the needs of transit operators. Based on the findings of TCRP Report 169, these Cases (Incidents Involving Days Away from Work, Job Transfers, or Restrictions)* Industry and NAICS Code ** Days Away from Work Job Transfers or Restrictions Subtotal Other Cases Total (all cases) All industries, including state and local government (N/A) 1 0.7 1.7 1.6 3.3 Transportation and warehousing (48-49) 2.0 1.2 3.2 1.3 4.5 Urban transit systems (4851) 3.6 1.3 4.9 1.8 6.7 Support activities for rail transportation (4882) 3.2 1.7 4.9 1.6 6.5 Support activities for road transportation (4884) 1.8 0.7 2.4 0.6 3.0 * Incidence rates represent the number of injuries and illnesses per 100 full-time workers. ** NAICS = North American Industry Classification System. Source: BLS (2016a) Table 1. Incidents involving days away from work, job transfers/restrictions, and other cases, 2015.

Literature Review and Baseline Data 19 health and wellness programs may have limited participation due partly to the nature of transit bus operator work schedules. That report demonstrated, in part, that successful wellness programs can lead to long-term healthier behaviors, reduce accidents, and reduce absenteeism. Best practices in transit worker health can benefit from a comprehensive, occupation- specific program that management and employees alike support, which is readily available for the participation of the entire workforce. This section presents examples of some successful approaches and identifies systemic barriers to health promotion success. At the core of the NIOSH guidelines for improving workplace well-being is the importance of regarding wellness and safety as a top priority in the organization. Treatment of medical issues related to transit operation may be costly, especially the implementation of new programs. An organizational culture that prioritizes health and wellness will treat the cost of the programs as a secondary consideration. Using some form of competition to incentivize fitness and nutrition has become a popular strategy in the corporate world due to its relatively low-cost and built-in incentive structure. Veolia Transportation (now TransDev) ran a “Biggest Loser” challenge to engage employees in wellness efforts (Petrie 2014). Agencies use competitions to encourage healthy behaviors such as smoking cessation, exercise, and healthy eating habits. Increasingly, insurance plans avail- able to employees offer lower premiums for participation in wellness programs. These schemes have become common among large employers; however, the overall efficacy of these programs in increasing employee health and lowering costs is unclear (Tu and Mayrell 2010). Compe- titions for weight loss or smoking cessation are reportedly effective for increasing program participation, but not necessarily effective for fostering long-term change (Tu and Mayrell 2010). Consequently, metrics that gauge the success of a health promotion program based on participation rate may have limited value in measuring health outcomes. Research shows that incentives combined with supportive practices (e.g., increasing access to care, thorough screenings, onsite treatment, and assistance with early risk identification) can lead to longer-term benefits. Preventive screenings and treatment are key to minimizing the damage of potentially life-threatening illnesses like cancer, cardiovascular disease, and diabetes. Hiring an outside wellness coordinator can lead to the success of innovative practices, as it reduces concerns about confidentiality and may allow flexibility in scheduling activities around drivers’ schedules. Interventions must be well-designed to be effective. Sleep apnea is one of the most common medical causes of fatigue, which is one of the largest contributors to vehicular crashes. For several years, the Southeastern Pennsylvania Transportation Authority in Philadelphia, Pennsylvania, has had a program that encourages awareness and treatment of sleep apnea. The agency regularly screens transit bus operators to test for and treat sleep apnea (Petrie 2014). The agency does not have a separate budget for a wellness program, however, which means that agency employees also serve as wellness coordinators. Additionally, no financial incentives are in place to participate in the screening, and drivers who test positive may lose their jobs if there are no interventions in place. Programs or practices that promote a culture of safety can mitigate risks that transit workers face, including aggressive passengers and road accidents. A survey reported in TCRP Report 174 yielded the finding that training programs that address accidents should do so from the stand- point of preventing future accidents rather than assigning blame for past accidents (Roberts, Retting, and Webb et al. 2015). The survey also identified the following characteristics of developing or improving safety culture: providing adequate training to workers, having open and frequent communication on safety, and establishing a high level of trust between manage- ment and frontline staff, among other goals.

20 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line 3.5 Cost-Effectiveness of Health and Safety Intervention Programs An actuarial study conducted by Bolnick, Millard, and Dugas (2013) concluded that well- ness programs could potentially affect approximately 25% of healthcare costs for working populations. The study used data from the Global Burden of Disease study (Murray and Lopez 1996) and the MEPS to estimate the savings that would result from lowering risk factors typically managed by healthcare promotion programs to their theoretical minimums. According to a 2015 estimate from the CDC, 86% of the nation’s $2.7 trillion annual healthcare expen- ditures are for people with chronic and mental health conditions, and these costs can be greatly reduced (CDC 2017). Among other illnesses that health promotion programs target, cardio- vascular diseases cost an average of $316 billion annually in the United States from 2012 to 2014. The total estimated cost of diagnosed diabetes in 2012 was $245 billion; of this, $69 billion represented decreased productivity associated with people being absent from work, less produc- tive at work, or unable to work at all (CDC 2017). After the introduction of wellness programs in many workplaces across the United States, an increasing number of employers want to know if they are effective. Programs are adding measures of outcomes, including behavioral, clinical, and health outcomes. Some research authors go so far as to say that “there is a brewing controversy about whether workplace health promotion programs in the United States work or do not work” (Goetzel, Henke, and Tabrizi et al. 2014). In analyzing studies of cost-effectiveness of health promotion programs for transit workers, the Econometrica team grouped the studies into three categories: • Research on the effects of wellness programs for employees and organizations in any industry, • Guidance to the transit industry on measuring cost-effectiveness, and • Studies providing analysis of return on investment (ROI) and other cost-effectiveness measures of transit programs. Extensive literature is available on the cost-effectiveness of workplace health promotion programs (Bolnick, Millard, and Dugas 2013). In 2010, a comprehensive review of more than 100 studies of health promotion programs summarized the ROI from 22 health promotion programs that met study criteria (Baicker, Cutler, and Song 2010). The authors found that the average return on $1.00 of investment in the 22 programs was $3.27 when measuring savings in health costs and $2.73 when measuring savings from reduced absenteeism. Individual studies also have shown positive ROIs for wellness programs: One study showed a ROI of $2.53 for every dollar spent on a wellness program taking place over 7 years (2005–2011) for 3,800 cohorts; however, it should be noted that this study focused on workers in an academic workplace, which has different physical demands than a transit environment (Dement, Epling, Joyner, and Cavanaugh 2015). A 2014 study by RAND examined the cost impacts of PepsiCo’s workplace wellness programs, which offered both lifestyle and disease management components. The lifestyle management programs did not reduce costs among employees, but the disease management components resulted in a 29% reduction in hospital admissions and an annual reduction in health care costs of $136 per member per month (Caloyeras, Liu, and Exum et al. 2014). Another study examined workers’ hospitalizations in the BJC Healthcare hospital system in St. Louis, Missouri (Gowrisankaran et al. 2013). In the latter study, the wellness program reduced the number of hospitalizations but did not reduce costs when comparing those workers who participated in the wellness program with those who did not. The studies discussed suggest that health promotion programs may have a meaningful financial benefit to transit agencies. However, other research demonstrates that wellness programs may not affect the bottom line. One example is a study of approximately 33,000 workers

Literature Review and Baseline Data 21 at retailer BJ’s Wholesale Club over a period of 18 months (Song and Baicker 2019). Some of the BJ’s locations offered the wellness program and others did not. The employees at the sites with the programs reported an increase in regular exercise (8.3%) and weight management (13.6%) as compared to employees in the non-participating sites, but their health and employ- ment outcomes were not statistically significantly different than the employees in the sites without wellness programs. They had no improvements in self-reported health measures; clinical markers of health, such as lower blood pressure or sugar levels; health care spending or utilization; or absenteeism, tenure, and job performance (Song and Baicker 2019; Abelson 2019). Another study of 4,800 university employees showed statistically insignificant differ- ences between the employees who participated in an incentivized wellness program and those who did not, as measured by sick days and healthcare spending (Jones, Molitor, and Reif 2019). The project team’s review of the literature identified a limited number of studies of the cost- effectiveness of programs specific to transit agencies. The successful programs examined in the literature review were provided adequate resources and were of a type that could easily start small and be scaled up. Of the six case studies of effective health promotion programs in TCRP Report 169, the Capital Metropolitan Transportation Authority (Capital Metro) health and wellness program in Austin, Texas, achieved returns of $2.43, $3.95, and $2.88 for each dollar in the years 2007, 2009, and 2010, respectively. The program included two onsite 24-hour fitness centers with free personal training/health assessments; annual cash incentives for health promotion activity; and improved access to healthy food, health education, and health and wellness outreach events. Since 2003, Capital Metro has done an annual benefit-cost analysis of the workforce wellness program. After initial increases in healthcare costs in 2007, the program saw a 4% decrease in costs and a decline in driver absenteeism from 10% to 7.6%. Overall, the program achieved a greater than 200% ROI for each year after 2007. The Denver Regional Transportation District also has more than 12 years of data showing a positive ROI for the physical therapy program it began in 2000 (Jacobsen 2018). Additional studies on truck drivers and bus drivers also showed cost savings. Trucks, Inc., employs a doctor and physician assistant to perform annual health screenings of drivers onsite. These screenings include routine bloodwork screenings and a check of prostate-specific antigen (PSA) levels in male workers. The company claims that early detections from the screening program have saved them $250,000 in medical costs and led to the early identification of five pre-heart disease conditions, two cancer cases, and many instances of prediabetic conditions (Krueger, Brewster, Dick, Inderbitzen, and Staplin 2007). Schneider National, another trucking company, took a different approach to sleep apnea intervention. The company identified drivers who could potentially suffer from sleep apnea, then paid for a third-party vendor to test the drivers and sent drivers who were diagnosed with sleep apnea home with a Continuous Positive Air Pressure (CPAP) machine. The com- pany followed up with drivers quarterly to ensure that the intervention was still working. Per the company’s statistics, this program saved an average of $500 per driver per month in healthcare costs and increased retention by more than 50% (Krueger, Brewster, Dick, Inderbitzen, and Staplin 2007). Studies on ergonomic improvements suggest that this is one area of program interven- tion that can alleviate musculoskeletal disorders among bus operators, reduce healthcare costs, and increase worker productivity. In one study, an ergonomist interviewed a sample of bus operators, observed driver habits, and synthesized data into a training program. The ergonomist’s consulting team subsequently trained and tested the entire bus operating force on the seating and found that the behavioral training alone reduced work-related musculo skeletal disorders by almost 30% (OSHA 2003). Although changing drivers’ seating can be costly, at least one company—Schneider National—has reported a decrease

22 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line in lost time injuries, discomfort complaints, and workers’ compensation injuries by 47% (Krueger, Brewster, Dick, Inderbitzen, and Staplin 2007). 3.6 Conclusions 3.6.1 Health and Safety Outcomes The work of operating vehicles (e.g., buses, light rail, or heavy rail vehicles) can lead to nega- tive occupational health outcomes such as musculoskeletal pain, acute back pain, and chronic health conditions such as diabetes, which are exacerbated by fatigue and stress levels. Operators may face safety challenges in the form of unruly or aggressive passengers, and they are also at risk of vehicle accidents by operating with occupational health injuries or chronic conditions, including insufficient sleep. Both vehicle operators and other transit workers face health issues due to exposure to exhaust fumes and other environmental hazards. Transit workers are three times more likely than the general public to have an injury that results in days away from work (absenteeism) and job transfer or restriction (turnover). Poor health may exacerbate driver distraction and increase the risk of work injury; likewise, work-related injuries may exacerbate or increase the risk of chronic conditions. 3.6.2 Costs of Chronic Illnesses and Injuries Transit workers have high prevalence rates of smoking and obesity, which are associated with higher medical costs. The chronic illnesses from which transit workers suffer dispro- portionately (e.g., diabetes, cancer, and hearing loss) carry medical and economic costs. For example, people with diabetes incur an estimated average of $7,900 per year in diabetes-related medical expenditures (American Diabetes Association 2013). Direct medical costs associated with some cancer treatments can range from hundreds to thousands of dollars per month (Yabroff, Lund, Kepka, and Mariotto, 2011). Costs related to fatal occupational injuries in transit and ground transportation workers were estimated to amount to more than $200 million per year in 2006 (CDC 2014). Injuries and the development of chronic illness in transit workers can create meaningful economic losses from reduced workdays, shortened career spans, and the costs of clinical care. 3.6.3 Programs to Mitigate Negative Health and Safety Outcomes Research on workplace wellness and safety interventions is still relatively new and the findings are mixed. At the core of the NIOSH guidelines for improving workplace well-being is the importance of regarding wellness and safety as a top priority in the organization. Many agencies use some form of competition to incentivize fitness and nutrition. This strategy has become popular in the corporate world due to its relatively low-cost and built-in incentive structure. Research shows that incentives combined with supportive practices (e.g., increasing access to care, thorough screenings, onsite treatment, and assistance with early risk identi- fication) can lead to longer-term benefits. To be effective, interventions must have an under- standable structure and goals that are communicated clearly to workers. Programs or practices that promote a culture of safety can mitigate risks that transit workers face, including aggressive passengers and road accidents. 3.6.4 Cost-Effectiveness of Health and Safety Intervention Programs The literature provides evidence of the direct costs of chronic health conditions, including absenteeism and turnover, and how wellness intervention programs function to mitigate

Literature Review and Baseline Data 23 these costs. Relatively few studies measure the indirect costs of occupational health injuries for transit workers, however, and very little data provide evidence for the effectiveness of wellness intervention programs for the transit worker population. In the existing literature on transit worker wellness programs reviewed by the project team, two studies included a review of six transit agencies that included one case with a twofold ROI and health intervention program for truck drivers that resulted in increased retention. Overall, the literature is largely inconclusive on the effectiveness of wellness programs to reduce costs, both in general and specifically for transit agencies. Most programs are not well supported, funded, or targeted to the unique challenges transit workers face. This research sought to close several gaps in the research on transit worker wellness and safety programs. Chapter 6 of this report presents an assessment of the cost-effectiveness of methods that agencies have used, describes the benefit- cost analysis conducted by the project team, and identifies ways to incorporate scalable and sustainable cost-effectiveness strategies into health promotion programs.