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Evidence Reports All of EHC



Total Worker Health® (TWH)

Systematic Review ARCHIVED May 31, 2016
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Archived: This report is greater than 3 years old. Findings may be used for research purposes, but should not be considered current.


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Structured Abstract


The purpose of this review is to provide an evidence report that the National Institutes of Health, Office of Disease Prevention, Pathways to Prevention Workshop Program can use to inform a workshop focused on Total Worker Health® (TWH). TWH is defined as policies, programs, and practices that integrate protection from work-related safety and health hazards with promotion of injury and illness prevention efforts to advance worker well-being. This review describes the body of evidence evaluating TWH interventions, assesses the benefits and harms of interventions, and highlights research gaps and future research needs.

Data sources

We searched MEDLINE®, the Cochrane Library, the Cochrane Central Trials Registry, and PsycINFO® from January 1, 1990, to September 21, 2015. Eligible studies included randomized controlled trials (RCTs), nonrandomized trials, and prospective cohort studies with a concurrent control group; single-group pre-post studies were also eligible for Key Questions (KQs) describing interventions or identifying contextual factors, research gaps, and future research needs.

Review methods

Pairs of reviewers independently selected, extracted data from, and rated the risk of bias of relevant studies; they graded the strength of evidence (SOE) using established criteria. We synthesized all evidence qualitatively.


We included 24 studies described in 33 publications. Fifteen studies had a concurrent control group (12 RCTs, 2 nonrandomized trials, and 1 cohort study) and were eligible for all KQs; 9 were pre-post studies. Studies were heterogeneous in terms of work settings and populations, interventions, and outcomes. For the 15 studies eligible for KQ 2, we rated 10 as high risk of bias primarily because of selection bias. Evidence of low SOE supported the effectiveness of TWH interventions for improving rates of smoking cessation (measured by self-reported 7-day abstinence) over 22 to 26 weeks and increasing the consumption of fruits and vegetables over 26 to 104 weeks; these results apply to populations of blue-collar manufacturing and construction workers. Evidence of low SOE supported the effectiveness of TWH interventions for reducing sedentary behavior at work over 16 to 52 weeks in office workers. Evidence was insufficient or completely lacking for other outcomes of interest (e.g., rates of work injuries, quality of life). Effective interventions were informed by worker participation and highlighted the potential synergistic risks of hazardous work exposures and health behavior. Work organization factors and union membership status were two commonly mentioned contextual factors that may have modified intervention effectiveness. Future studies should try to directly assess the effectiveness of integration itself by isolating the benefits (or harms) of integration from other components; future studies should also focus on outcomes related to occupational safety and health (OSH).


The body of evidence was small and diverse in terms of populations, interventions, and measured outcomes. TWH interventions were effective in improving intermediate outcomes traditionally measured in health promotion programs (smoking cessation and fruit and vegetable consumption) and reducing sedentary work behavior. Future research should be designed to evaluate the effect of integration by itself (separately from new or improved OSH and health promotion components) and assess the effect of integration on outcomes related to OSH.

Journal Publications

Feltner C, Peterson K, Weber RP, et al. The effectiveness of Total Worker Health interventions: a systematic review for a National Institutes of Health Pathways to Prevention Workshop. Ann Intern Med. 2016 May 31 [Epub ahead of print]. DOI: 10.7326/M16-0626. PMID: 27240022.

Page last reviewed December 2019
Page originally created November 2017

Internet Citation: Systematic Review: Total Worker Health® (TWH). Content last reviewed December 2019. Effective Health Care Program, Agency for Healthcare Research and Quality, Rockville, MD.

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