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t h e

S c i e n c e o f l i f e s t y l e c h a n g e

Literature Review: Population Health; Total Worker Health

Integrated Approaches to Occupational Health and

Safety: A Systematic Review
A. Cooklin, PhD;
PhD; N.
N. Joss,
Joss, MPH,
MPH; PhD; E. Husser,
E. Husser, MSc; MSc; B. Oldenburg,
B. Oldenburg, PhD PhD

Objective. The study objective was to conduct a systematic review of the effectiveness of integrated
workplace interventions that combine health promotion with occupational health and safety. Integrated approaches to occupa-
Data Source. Electronic databases (n ¼ 8), including PsychInfo and MEDLINE, were systematically tional health, safety, and well-being
searched. have been conceptualized in the inter-
Study Inclusion and Exclusion Criteria. Studies included were those that reported on workplace national scientific literature for ap-
interventions that met the consensus definition of an ‘‘integrated approach,’’ published in English, in the
proximately two decades. A growing
scientific literature since 1990.
Data Extraction. Data extracted were occupation, worksite, country, sample size, intervention targets, body of literature has emerged to
follow-up period, and results reported. Quality was assessed according to American College of support organizations and employers
Occupational and Environmental Medicine Practice Guidelines. with the implementation of integrated
Data Synthesis. Heterogeneity precluded formal meta-analyses. Results were classified according to the approaches.1–4 Despite this momen-
outcome(s) assessed into five categories (health promotion, injury prevention, occupational health and tum, the empirical evidence describing
safety management, psychosocial, and return-on-investment). Narrative synthesis of outcomes was the implementation or efficacy of
performed. integrated approaches to worker
Results. A total of 31 eligible studies were identified; 23 (74%) were (quasi-)experimental trials. health, safety, and well-being is sparse.5
Effective interventions were most of those aimed at improving employee physical or mental health. Less
In the climate of current interest for
consistent results were reported from integrated interventions targeting occupational health and safety
management, injury prevention, or organizational cost savings.
integrated approaches as an effective
Conclusion. Integrated approaches have been posed as comprehensive solutions to complex issues. way forward for workplace health
Empirical evidence, while still emerging, provides some support for this. Continuing investment in, and promotion, a review of the evidence is
evaluation of, integrated approaches are worthwhile. warranted and timely. This paper aims
Key Words: Occupational Health, Occupational Safety, Occupational Health to systematically review the empirical
Promotion, Systematic Review, Occupational Health Management. Manuscript evidence about integrated approaches
format: literature review; Setting: workplace; Health focus: physical activity, to worker health, safety, and well-being.
nutrition, smoking control, stress management, weight control; Strategy: education, Integrated approaches combine oc-
behavior change, policy, culture change, built environment; Target population age: cupational safety and injury prevention
adults; Target population circumstances: education; income level with health promotion to protect and
promote worker health, safety, and
well-being.6–8 Hymel et al.8(p695) define
integrated approaches as ‘‘the strategic
and systematic integration of distinct
environmental, health and safety poli-
cies and programs into a continuum of
activities that enhances the overall
health and wellbeing of the workforce,

A. Cooklin, PhD, is with the Judith Lumley Centre, La Trobe University, Melbourne, Australia. N. Joss, MPH, PhD, is with the University of Melbourne,
Melbourne, Australia; A. Cooklin, PhD; E. Husser, MSc; and B. Oldenburg, PhD, are with the School of Public Health and Preventive Medicine, Monash
University, Melbourne, Australia. B. Oldenburg, PhD, is with the Melbourne School of Population and Global Health, University of Melbourne, Melbourne,
Australia. .
Send reprint requests to Amanda R. Cooklin, PhD, Judith Lumley Centre, La Trobe University, 215 Franklin Street, Melbourne, VIC 3000, Australia;
This manuscript was submitted October 27, 2014; revisions were requested February 2, 2015; the manuscript was accepted for publication September 10, 2015.

Copyright Ó 2016 by American Journal of Health Promotion, Inc.

0890-1171/00/$5.00 þ 0
DOI: 10.4278/ajhp.141027-LIT-542

American Journal of Health Promotion September 2017, Vol. 31, No. 5 401
and prevents work-related injuries and broad range of settings and outcomes
illnesses.’’ Underpinned by a socio- (Table 1).
ecologic understanding of the source Table 1
PICOS Definitions
of risks to worker health, integrated OBJECTIVE
approaches incorporate health pro-
PICOS Definition
motion, organizational development,
The specific aims of this review were: Population Employers/organizations/
and psychosocial and physical working
environments.6,9–13 1. To systematically review the effec-
A strong rationale for integrated Australian and international
tiveness of integrated interventions Small-large enterprises
approaches has been advocated from against the (individual, organiza- All sectors
several bases, including clinical expe- tional, psychosocial, or environ- Interventions Workplace program(s)
rience in diverse occupational set- mental) outcomes; and implementing integrated
tings8,14; partnerships with industry15; 2. To investigate whether integrated approach(es) to worker
improving systems and organizational approaches were more effective health, safety, and well-
efficiency12,16,17; the complementary against targeted intervention out- being (i.e., occupational
skill set of occupational health and comes than those using a more health and safety and
health promotion practitioners12,15; well-being, health
traditional ‘‘nonintegrated’’ ap-
promotion), defined by
and economic efficiencies.17 proach. study criteria
However, ascertainment of ‘‘integra- Comparison Baseline data, or
tion’’ in the published scientific litera- Operational Definition of Integrated groups Preintervention group, or
ture is difficult because the focus is on Approaches Control group
the reporting of intervention effects, To derive an operational definition Outcomes Employee health promotion
rather than implementation and pro- of ‘‘an integrated approach,’’ we Employee injury prevention,
cesses.5 Terminology and focus are adapted a core set of criteria3,4,25
mixed between settings and countries. occupational health and
recently summarized by Sorensen et safety management;
Efforts in the United States have been al.5(pS16) into four indicators: (1) or- psychosocial outcomes
toward reducing individual health ganizational leadership and commit- Organizational costs, direct
risks.3,18,19 By contrast, the focus in ment; (2) coordination between health and indirect
Canada, Europe, and the United protection (OHS) and HP; (3) sup- Study Pre-post comparisons
Kingdom has been toward optimizing portive organizational policies and designs (Quasi-)Experimental trials
psychosocial conditions in the work- practices; and (4) comprehensive pro-
place.2,20–22 However, many of these gram content. Studies meeting at least
recommendations are yet to be trans- criteria (2) were included in the review. gories were combined with the
lated into workplace programs that Boolean operator ‘‘AND,’’ and search
could be subject to systematic evalua- Method
terms within each category were com-
tion; thus, evidence is in its relative A systematic review of the evidence
bined with ‘‘OR.’’
infancy.15,23 was conducted. Reporting follows the
Nonetheless, given the burgeoning recommended items outlined in the Inclusion and Exclusion Criteria
interest in integrated approaches, a Preferred Reporting Items for System- Inclusion and exclusion criteria are
systematic review of extant evaluations atic Reviews and Meta Analyses (PRIS- presented in Table 2.
of integrated programs that have been MA Statement).24
trialed is timely. Our overall purpose Data Sources A two-stage review process was ap-
was to systematically review the empir- English-language articles published plied (Figure). First, abstracts were
ical evidence about the effectiveness of in the peer-reviewed literature between reviewed by a first author (A.C.), and
integrated approaches that combine January 1990 and September 2013 ineligible study designs were excluded.
occupational health and safety (OHS) were searched (August–September Full-manuscript review by two authors
with health promotion (HP) to pro- 2013) from journals indexed in the (A.C., N.J.) was conducted indepen-
mote worker health, safety, and well- following databases: MEDLINE, Em- dently to ascertain eligibility. Adjudi-
being. Our focus was to review inter- base, PsychInfo, CINAHL, Scopus, Web cation was by a third author (E.H.)
ventions implementing an ‘‘integrated of Science, ProQuest, and The Co- when there was not consensus.
approach’’ rather than any one partic- chrane Library. There were two search
ular OHS outcome. Although under- categories: those pertaining to OHS Data Extraction
standing the effectiveness of integrated (e.g., occupational health/safety) and Items in the data extraction form
approaches targeting particular out- those identifying workplace HP (health included: occupation, worksite, coun-
comes in specific sectors would be promotion, wellness). Variations on try, sample size, intervention targets,
valuable, the evidence is not yet suffi- the terms ‘‘integrated approach’’ were intervention content (referent group),
ciently developed to allow for these then applied (e.g., integrated, whole, follow-up period, results reported (Ta-
targeted research questions. Accord- total, combined, complete, compre- ble 3). Items to assess methodologic
ingly, our PICOS24 criteria allow for a hensive, holistic, whole worker). Cate- quality were also extracted.

402 American Journal of Health Promotion September 2017, Vol. 31, No. 5
Table 2 Table 3
Study Inclusion and Exclusion Criteria Summary of Included Studies (N ¼ 31)*

Eligible Studies Met All Criteria Ineligible Studies Met Any Criteria Characteristic No. (%)
Evaluation of a workplace program or Reports of baseline data, etiologic data, Year of publication
intervention qualitative, or study protocols; systematic 1990–2000 8 (26)
reviews 2001–2009 14 (45)
Program managed internally within the External management (e.g., primary health 2010–2014 9 (29)
workplace care) Country
Demonstrated ‘‘integrated’’ according to Reporting on programs/interventions with no Canada 2 (6)
Indicators of Integrated Approaches* evidence of integrated approach, or reporting United States 16 (53)
insufficient information to ascertain an United Kingdom and Europe 12 (40)
integrated approach Japan 1 (,1)
Industry type
* Sorensen et al.5
Manufacturing 14 (46)
Primary health care 7 (23)
Amenities supply 4 (13)
Government department 3 (10)
Protective services 2 (7)
Construction 1 (,1)
No. of outcomes assessed (range, 1–21)
1–3 10 (33)
4–6 13 (42)
7–10 6 (19)
Figure .10 2 (6)
No. of studies assessing†
Identification of Study Sample Physical health/behaviors 17 (55)
Safety and injury prevention 4 (13)
OHS management 3 (10)
Psychosocial 6 (19)
Costs 9 (29)
Process outcomes 5 (16)
No. of studies comparing integrated
vs. standard interventions 4 (13)
Methodologic quality‡
Low 5 (16)
Moderate 22 (71)
High 4 (13)
* OHS indicates occupational health and
† Total .100%, studies reporting on .1
‡ American College of Occupational and
Environmental Medicine guidelines (Harris et
al. ); scores 0–3.5 are low quality; 4–7.5 are
moderate quality; and 8–11 are high quality.

Assessment of Methodologic Quality

Study quality was assessed using the
American College of Occupational and
Environmental Medicine’s Practice
Guidelines.26 Studies were rated (0,
not done/reported; 0.5, partially
done/described; 1.0, fully conducted/
reported) on 11 aspects of design,
blinding, compliance, dropout, and
analysis, yielding a total score range of
0 to 11 (scores: 0–3.5 were ‘‘low’’; 4–7.5
were ‘‘moderate’’; and .8 were ‘‘high’’

American Journal of Health Promotion September 2017, Vol. 31, No. 5 403
Data Synthesis Intervention Targets and Outcomes assessed (worksite analysis, risk pre-
The heterogeneity of study designs, Assessed vention, OHS training and education).
interventions, and outcomes preclud- Most studies assessed between four Four studies of moderate to high
ed the conduct of a formal meta- and six primary and secondary out- quality (scores 4–8) showed promising
analysis. A narrative approach to data comes (range, 1 to .10; total .100%). effects on several indicators of the
synthesis was conducted in three stag- Targets of interventions, as well as psychosocial work environment, in-
es: (1) description of study character- outcomes reported, were classified and cluding improved job quality,39 re-
istics; (2) assessment of methodologic summarized (Table 3). Most focused duced occupational stress,49 reduced
quality; and (3) narrative synthesis of on physical health/health behaviors (n symptoms of depression,41,50 and im-
results to address study aims. For step ¼ 17; 55%), followed by analyses of proved psychological resources.50 Two
(3), results from individual studies costs (n ¼ 9; 29%), psychosocial out- studies reported a mixed pattern of
were classified as follows: employee comes (n ¼ 7; 23%), safety/injury effects on occupational stress and
health promotion, employee injury prevention (n ¼ 4; 13%), or OHS psychological resources.37,51
prevention and treatment, occupa- management, with 5 process evalua- Of the nine studies reporting on
tional health and safety management, tions (16%). Most (n ¼ 21; 67%) various cost-related outcomes, findings
psychosocial outcomes, and direct and reported on primary study outcomes were equivocal. Five studies reported
indirect organizational costs. that were intermediate ‘‘soft’’ indica- favorable effects on absenteeism, leave
tors (e.g., health behaviors, safety usage, or short-term disability
protocols). Only 10 studies (32%) days.28,39,41,44,52 Four reported few or
reported on ‘‘hard’’ outcomes: costs (n no effects on cost outcomes (health
¼ 9) or mortality (n ¼ 1). care costs, sick leave).31,37,43,45
Of 671 abstracts screened, 82 were
subject to full review, with 31 papers Summary of Effectiveness of Effectiveness of ‘‘Integrated’’
(24 separate studies) eligible for in- Integrated Interventions (Study Aim 1) Compared With ‘‘Standard’’
clusion (Figure). Of the studies targeting employee Interventions (Study Aim 2)
health/health behavior (17 total, 14 Four papers (two studies) compared
Characteristics of Included Studies standard HP interventions with inter-
Characteristics of included studies separate interventions), outcomes as-
ventions integrating HP with OHS.
are presented in Table 3. Most studies sessed were tobacco use, weight man-
The WellWorks-2 study compared a
(n ¼ 22; 71%) were classified as agement, physical activity, nutrition,
cancer risk-reduction intervention in
‘‘moderate’’ quality, with four (13%) self-rated health, chronic disease inci-
two modes: HP only, and integrating
classified as ‘‘high’’ and the remainder dence, and mortality. Most studies (n ¼
HP with workplace environmental
‘‘low’’ (n ¼ 5; 16%). Most were set in 9) reported favorable effects against
amelioration of exposure to occupa-
the United States, followed by the the targeted health outcomes.30–38
tional hazards (HP-OHS arm). Hunt et
Fewer reported either mixed effects (n
United Kingdom and Europe, and al.53 found increased participation per
manufacturing was the most common ¼ 3)29,39,40 or no effects (n ¼ 2).41,42
intervention activity (21.1% vs. 14.2%),
industry represented. Integrated interventions targeting longer duration of worker exposure to
Individual study summaries, includ- injury prevention and safety (n ¼ 4) the intervention activities (33.3 vs. 14.9
ing details of the integrated interven- focused on the prevention, treatment, minutes), and higher overall mean
tions, are presented in Tables 4 and 5. or management of musculoskeletal participation (45.8% vs. 34.4%) for
Most studies met more than the single disorders (MSDs), with three of these employees in the integrated worksites
indicator for integrated approaches four studies sampling nursing/health (HP-OHS), compared with those in the
based on the Sorensen et al.5 criteria. care workers.43–45 Two reported a standard (HP-only) delivery worksites.
Study samples ranged from 40 to decrease in the prevalence of Further, blue-collar workers had a
24,586 participants. A total of 14 MSDs,27,44 one an increase,43 and one higher smoking cessation rate in the
studies (45%) were experimental trials no significant effects on incidence.45 integrated arm (11.8% vs. 5.9%).36
with randomized group assignment; 9 Three studies assessed OHS man- Goetzel et al.32 compared a moderate
(29%) were quasi-experimental trials agement (OHS program content, or- (HP-only) intervention with an intense
comparing the intervention and a ganizational health/safety climate). In intervention integrating HP with orga-
(nonrandom) referent group; and 8 two instances these studies reported nizational change. Both interventions
(26%) were a single-group design improvements in some, but not all, stabilized employee body mass index
relying on pre-post comparisons. With aspects of the health and safety cli- (BMI), where BMI increased in control
the exception of three studies follow- mates evaluated: Kines et al.46 and sites, but there were no additional
ing participants for 4 years,27 7 years,28 Basen-Engquist et al.47 LaMontagne et intensity effects on other employee
and 10 years,29 follow-up periods were al.48 found improvements to ‘‘man- outcomes (blood pressure, nutrition,
brief, from 1 month to 3 years. Only agement commitment and employee smoking and alcohol use, stress). Im-
two studies (four papers) compared an participation’’ from the WellWorks-2 provements in physical activity and
integrated ‘‘intensive’’ intervention cancer-prevention intervention, but cholesterol (intense arm) disappeared
with a nonintegrated ‘‘moderate’’ ver- there were no significant effects on once analyses controlled for clustering
sion of the intervention (Table 5). other elements of OHS functions effects. Significant mean score im-

404 American Journal of Health Promotion September 2017, Vol. 31, No. 5
Table 4
Summary Characteristics and Results of Studies Reporting on Integrated Interventions (All Comparison Groups; n ¼ 27)*

Occupation/ Indicators of Intervention (Control Effectiveness

Workplace/ Target of Integrated or Comparison Follow- Against Targeted Quality
Source Country (No.) Intervention Approaches† Group) Up Outcomes Score‡
Badii et al.,43 Health care workers/ Musculoskeletal Coordination HP-OHS Workplace modification; 12 mo Increased rate (per 100,000 h) 1.5
2006 acute-care hospital/ injury early identification; MSDs at intervention site
Canada (N ¼ 216) therapy; work (7.6–9.2; 0.02); reduced RR
accommodation while in (1.0) for time loss compared
recovery; access to on- with historical data (RR ¼
site physician 1.14, p , 0.001); null
(control historical data) results medical costs
Barbeau et al.,30 Iron worker Reduction and Coordination HP-OHS; Health education; smoking 1 mo Participants OR ¼ 3.0 for 3.5
2006 apprentices/ cessation in comprehensive cessation support group; quitting; increased intention
multiworksite tobacco use program content nicotine therapy; health to quit participants vs.
training program/ promotion materials and controls (50% vs. 20%; p ¼
United States (N ¼ incentives delivered 0.006); decreased intensity
337) within OHS training (66.7% vs. 17.7%; p ,
(single group pre-post 0.0001) and frequency
design) (52.4% vs. 14.9%; p ¼
Basen-Engquist Blue-collar and white- Organizational Coordinated Lifestyle cancer prevention 3y Organizational health climate 7.5
et al.,471998 collar employees/40 health and management (diet, smoking); increased (F ¼ 7.57, p ¼
gas and electricity safety climate strategies; education, support, and 0.009); no main effect
suppliers/United comprehensive relapse prevention via safety climate; electrical
States (N ¼ 6867) program content; health promotional worksites decreased safety
coordination HP- activities, classes, self- climate at follow-up (F ¼
OHS help, and group support 6.02, p ¼ 0.02)
(matched worksites,
standard health
promotion materials
Bergström et al.,31 Blue-collar and white- Health behaviors; Comprehensive Clinical examination and 3.5 y Significant reduction in 4.0
2008 collar staff/4 HRQoL; sick program content; rehabilitation for smoking over time for 3 (of
manufacturing leave usage coordinated individual ‘‘at risk’’ 4) sites; no change in
worksites/Sweden management and employees; work group– exercise habits; 2 (of 4)
(N ¼ 4894) employee level survey feedback to companies improved
engagement; address psychosocial HRQoL; 1 site reported
coordination HP- climate (single-survey decreased sick leave
OHS feedback at baseline for
1 worksite)
Curwin et al.,27 White-collar staff/12 Musculoskeletal Coordinated Education workshops and 4y MSD prevalence reduced 6%– 3.0
2013 sites govt. injury management written material; 12% in 8 sites; decreases in
department/Canada strategies; workplace assessment; shoulder (14%–6%) and hip
(N¼233) comprehensive individual consultations (8%–3%) injuries;
program content; and referral; strength decreased upper back
coordination HP- training (baseline data) (14%–5%) and lower back
OHS (23%–12%), but not other
pain regions; proportion
those reporting 0–2 pain
regions increased (43%–
60%; p , 0.0001)
Cunningham Health care workers/ Back pain Coordination HP-OHS; HP campaigns tailored for 2y Improvement in attitude and 3.0
et al.,45 2008 hospital/Ireland (N ¼ coordinated managers, staff, and belief mean scores;
228) management clinicians; establish improved intention to self-
strategies; integrated database and manage back pain (e.g.,
comprehensive management path, remain active; 22%–36%; p
program content across a 2-y period ¼ 0.001); no decrease in
(baseline data) leave due to back pain
Elliot et al.,33 Firefighters/5 fire Nutrition; weight; Coordination HP-OHS Individual-delivery 3 mo Both intervention groups (cf. 8.5
2007 departments/United physical activity motivational counseling; control): cholesterol (F ¼
States (N ¼ 696) team-centered delivery 4.06, p ¼ 0.03); individual
(control group written arm better diet (F ¼ 4.06, p
info only) ¼ 0.03), decreased
depression (F ¼ 3.34, p ¼
0.05); team delivery
increased exercise; no
effects on BMI, oxygen,
fruit/vegetable intake

American Journal of Health Promotion September 2017, Vol. 31, No. 5 405
Table 4, Continued
Summary Characteristics and Results of Studies Reporting on Integrated Interventions (All Comparison Groups; n ¼ 27)*

Occupation/ Indicators of Intervention (Control Effectiveness

Workplace/ Target of Integrated or Comparison Follow- Against Targeted Quality
Source Country (No.) Intervention Approaches† Group) Up Outcomes Score‡
Elo et al.,49 Employees/ Stress reduction Coordinated Survey feedback method 3y Improved job variability (v2 ¼ 4.0
1998 manufacturing co./ management and (baseline data) 10.7, p , 0.03); reduced
Finland (N ¼ 118) employee mental (v2 ¼ 16.5, p ,
engagement 0.002) and physical (v2 ¼
strategies; 10.1, p , 0.0) stress
coordination HP-
Kawakami et Blue-collar employees/ Stress reduction Coordinated 2 sites: staff and 2y Reduced depression (F ¼ 5.0
al.,41 1997 electric co./Japan (N management; supervisors identify 3.41, p ¼ 0.04); reduced
¼ 297) comprehensive stressors and solutions, sick leave (v2 ¼ 10.4, p ¼
program content; and implement changes 0.03); no effect blood
coordination HP- to work processes (3- pressure; overtime;
OHS site control group) stressors
Kines et al.,46 Employees/14 SMEs Injury prevention; Processes for 8 sites: safety coaching for 6 mo Improvement on 6 (of 8) 7.0
2013 metal industry/ safety culture manager owner/manager; safety culture indices; no
Denmark (N ¼ 202) accountability and consultations with staff; effect on worksite safety
training; coordinated survey feedback (8-site index
management and matched control)
employee strategies;
coordination HP-
Kuehl et al.,28 Firefighters/4 fire Worker Coordination HP-OHS 2-site intervention (see 7y 8% reduction in total WC 5.0
2013 departments/United compensation Elliot et al.,33 2007) (2- claims (vs. 13% increase
States (N ¼ 1369) claims; medical site matched control) control departments); claims
costs rate 28% vs. 32% (p ,
0.001); 7% increase per
head (cf. 24% increase);
ROI: 1.8–4.6 to 1
LaMontagne et 15 large manufacturing OHS program Coordination HP-OHS 7 intervention (see 2y Improvement management 8.5
al.,48 2004 worksites/United content Sorensen et al.,36 2002) commitment/employee
States (8 control sites) participation element (mean
change, 2.89; p ¼ 0.03), but
not other 3 elements of
OHS content
Maes et al.,39 Employees/3 sites Health behaviors; Coordination HP-OHS; 1 intervention site: health 3y No effect health behaviors; 5.0
1998 manufacturing co./ stress; work processes for education; training for reduced cholesterol males
Netherlands (N ¼ quality; manager management; only (F ¼ 5.61, p ¼ 0.02);
264) absenteeism accountability, environmental change no effect stress; improved
training; coordinated and wellness committee; job quality; reduction in
management and continual improvement absenteeism
employee strategies (2 control sites)
Nelson et al.,44 Nurses/23 acute care Injury rates; lost Coordination HP-OHS Intervention protocol for 9 mo Reduced injury rate 24% vs. 3.5
2006 hospital units/United days; job ergonomic assessment; 17%; reduced days modified
States (N ¼ 300) satisfaction; patient handling, lifting, duties, median, 6.2 vs. 10.2;
unsafe incidents; policies, and procedures no effect lost work days;
ROI; med costs (baseline data) decreased unsafe incidents;
increased job satisfaction;
savings of $245,727
Okechukwu et Construction Smoking cessation Coordination HP-OHS Intervention (4 sites) 6–9 mo Short-term quit rates 26% vs. 6.5
al.,40 2009 apprentices/10 sites/ delivered within OHS 16% (OR ¼ 1.62) not
United States (N ¼ curriculum, group sustained at 6 mo; reduced
1213) counseling; quit kits; smoking intensity (OR ¼
environmental 3.1) sustained; no effect
messages and supports smoking frequency, quit
(waitlist control 6 sites) attempts, or intention
Ott et al.,29 2010 Cohort employees/ Chronic disease Coordination HP-OHS; Health seminar program 1–10 y No effect on disease 4.5
manual, skilled incidence; comprehensive incorporating incidence; reduced mortality
production/Germany mortality program content ergonomics, lifestyle, of 13%–17% estimates
(N ¼ 24,586) stress, coping, and
physical activity
(baseline data)

406 American Journal of Health Promotion September 2017, Vol. 31, No. 5
Table 4, Continued
Summary Characteristics and Results of Studies Reporting on Integrated Interventions (All Comparison Groups; n ¼ 27)*

Occupation/ Indicators of Intervention (Control Effectiveness

Workplace/ Target of Integrated or Comparison Follow- Against Targeted Quality
Source Country (No.) Intervention Approaches† Group) Up Outcomes Score‡
Petterson et al.,51 Nursing staff/14 elder- Self-reported Coordinated Intervention: train-the- 8 mo Improved general health; 5.5
2006 care units/Sweden health; health management and trainer; competence increased MSD symptoms;
(N ¼ 200) resources employee circles to tailor greatest effects in home-
engagement intervention to address care staff (vs. on-site staff)
strategies; OHS/health/stress/work
comprehensive design (baseline data)
program content;
coordination HP-
Serxner et al.,52 Employees/large Short-term Coordination HP-OHS; Intervention included: 2y Control STD days increased 5.0
2001 telecommunication disability days comprehensive OHS, ergonomics; by 15% during follow-up;
co./United States (N program content fitness center; weight participants decreased by
¼ 1628) management; smoking 5%, F ¼ 6.64, p , 0.01
cessation; counseling
(control: nonparticipants)
Sorensen et al.,35 Employees/24 Participation in Comprehensive Intervention: integrated 2y Less participation (nutrition) 7.5
1996 manufacturing intervention program content; governance and men (OR ¼ 0.44); blue
worksites/United programs coordinated program planning; collar (OR ¼ 0.66); higher
States (N ¼ 2658) management and environmental changes; participation when
employee strategies; education (12 control integrated with health
coordination HP- worksites) protection (OR ¼ 1.58); and
OHS perceived positive employer
changes to reduce
exposures (OR ¼ 1.54)
Sorensen et al.,58 Employees/24 Nutritional intake; Coordinated Intervention: integrated 2y Reduced fat intake 2.2% (p , 7.5
1998 manufacturing smoking management and governance and 0.01); increased fiber intake
worksites/United cessation employee strategies; program planning; 12% (p ¼ 0.01); increase
States (N ¼ 2658) coordination HP- environmental changes; fruit/vegetable (þ4% vs.
OHS education (12 control þ9%; p ¼ 0.04); no
worksites) significant effect smoking
Sorenson et al.,34 Employees/26 small Nutrition; vitaminComprehensive Intervention: individual; 18 mo No overall effects except 6.5
2005 business use; physical program content; manager and multivitamin use; effects
manufacturing activity coordinated environmental change; higher for workers (cf.
worksites/United management and reducing occupational managers) for fruit/
States (N ¼ 974) employee strategies; hazards (smoking vegetable intake (5.5 vs.
coordination HP- cessation program) 7.5); for physical activity (
OHS 2.0 cf. 7.1)
Hunt et al.,55 2007 Employees/26 small HP program Coordinated Intervention: individual; 2 mo 58% (cf. 3.9% control) health 6.5
business awareness; HP management and manager and program awareness; 74%
manufacturing program employee strategies; environmental change; (cf. 29% in control sites)
worksites/United participation coordination HP- reducing occupational participation
States (N ¼ 1408) OHS; process for hazards (smoking
training/ cessation program)
Talvi et al.,42 1999 Employees/2 oil Diet; exercise; Coordination HP-OHS Intervention site: HP 3y Improved physical activity (OR 4.5
refineries/United physical activity; assessment, counseling, ¼ 1.94) but not other
States (N ¼ 885) MSDs; obesity; and referral outcomes
blood pressure; (assessment, written
smoking info only)
Tveito and Female nurses/nursing Sick leave; Comprehensive Intervention: physical 9 mo No effects primary/secondary 6.0
Eriksen,37 2009 home/Norway (N ¼ HRQoL; coping; program content; exercise; stress outcomes except subjective
40) job quality; coordination HP- management; health health ratings improved
subjective health OHS information; workplace
ratings assessment (waitlist
Verweij et al.,38 ‘‘At risk’’ employees/ Physical activity; Comprehensive Intervention: care 6 mo No effect weight or physical 8.5
2012 medium to large sedentary program content; according to new activity except for those with
enterprises/ behavior; diet coordination HP- integrated OH practice highest BMI; decreased
Netherlands (N ¼ and weight OHS guidelines (usual care) sedentary behavior;
523) increased fruit intake

American Journal of Health Promotion September 2017, Vol. 31, No. 5 407
Table 4, Continued
Summary Characteristics and Results of Studies Reporting on Integrated Interventions (All Comparison Groups; n ¼ 27)*

Occupation/ Indicators of Intervention (Control Effectiveness

Workplace/ Target of Integrated or Comparison Follow- Against Targeted Quality
Source Country (No.) Intervention Approaches† Group) Up Outcomes Score‡
Verweij et al.,59 Occupational care Process (As above) (As above) (As above) Reach ¼ 86%; attendance 6.5
2011 physicians (N ¼ 7), evaluation 4.4/5.0 sessions;
and employees satisfaction 7.6/10; fidelity
(N ¼ 274)/medium mixed
to large enterprises/
Vuori et al.,50 Employees/17 Depression, Coordination HP-OHS Intervention: group training 7 mo Increased work engagement, 8.0
2012 organizations/ fatigue; work for career efficacy mental resources, CME;
Finland (N ¼ 718) engagement; (written information only) reduced depression and
career self- intention to retire; no effect
efficacy fatigue

* HP indicates health promotion; OHS, occupational health and safety; MSD, musculoskeletal disorder; OR, odds ratio; RR, relative risk; HRQoL,
health-related quality of life; BMI, body mass index; SME, small-medium enterprises; WC, worker’s compensation; ROI, return on investment; STD, short-
term disability; and CME, career management efficacy.
† Based on Sorensen et al.,5 Indicators of Integrated Approaches (Table 2, p.S16).
‡ American College of Occupational and Environmental Medicine Practice Guidelines, Harris et al.26

provements on the study-specific envi- emerging, and research design has, for improved health outcomes, evidenced
ronment assessment tool were found the most part, yet to reach ‘‘gold in the heightened reach and effective-
for the intense arm only.54 standard.’’ Given these constraints, it is ness that several of the interventions
worth interpreting the results of this reported to sectors of the workforce
CONCLUSIONS review with some caution. that are normally hard to reach in HP
Our first aim was to review the interventions—blue-collar workers or
effectiveness of integrated approaches home care nurses, for example.36,51,53
Despite growing interest and mo- against targeted intervention out- Integrated interventions targeting
mentum, empirical evidence about the comes, which we classified into five injury prevention and safety have to
effectiveness of integrated approaches broad categories, of which physical date focused on the prevention,
to worker health, safety, and well-being health and health behaviors were the treatment, and management of MSDs.
has been slow to emerge. This study is most common (55% of studies). Of Current evidence was equivocal, and
one of the first studies to systematically these, interventions (and thus primary the studies were of low quality. Two
review the extant scientific evidence outcomes) varied widely, particularly in reported a decrease in the prevalence
about the effectiveness of workplace the degree to which organizational- of MSDs,27,44 one reported an in-
health and safety integration. Our level or environmental-level change crease,43 and one reported no signif-
focus here was on integrated ap- was targeted. Most studies reported icant effects on incidence.45 The study
proaches to health and safety protec- effects in favor of the intervention (n ¼ reporting the most widespread
tion in the workplace rather than on 9),30,31,33–38,54 with fewer reporting changes in favor of the intervention
any particular health risk, or occupa- mixed effects (n ¼ 3)29,39,40 or no was also that which implemented
tional exposure or outcome per se. effects (n ¼ 2).41,42 Overall, this yields substantive ‘‘upstream’’ organizational
Heterogeneity precluded formal ana- promising effectiveness in improving change to support individual behavior
lytic review; we synthesize findings worker health behaviors. With one change.44 Although individual behav-
from a range of study designs, across a exception,30 these studies were among ior change via new policies, practices,
broad range of health and safety the moderate- to high-quality studies and tailored information and assess-
outcomes assessed. (score range, 4–8.5), suggesting some ment was included in two further
Most studies were of moderate confidence in attributing the positive interventions,27,43 these reported lim-
(rather than high or low) quality, with effects to the intervention. ited or few intervention effects. Over
some design and conduct limitations as Notably, findings indicate that and above the latter two, the Nelson
classified by the ACOEM Practice worker engagement is heightened intervention engaged the organiza-
Guidelines.26 Further, most studies when personal health behavior inter- tion not only as a support for individ-
reported on intermediate or precursor ventions are delivered in a context of ual behavior change, but also as a
outcomes, rather than the ‘‘harder’’ occupational safety and organizational target of intervention itself, and a
outcomes of mortality or costs. This responsibility.29–31,33,36,37,55 This sug- means of embedding, implementing,
reflects that results from this body of gests an important pathway via which and sustaining strategies for injury
evidence are encouraging yet still integrated interventions can deliver prevention.56 Overall, however, this

408 American Journal of Health Promotion September 2017, Vol. 31, No. 5
Table 5
Summary Characteristics and Results of Studies Comparing Standard to Integrated Interventions (n ¼ 4)*

Occupation/ Risk Category (i.e., (Control or Effectiveness
Workplace/ Aim or Target of Criteria for Comparison Follow- Against Targeted Quality
Source Country (No.) Intervention) Inclusion† Group) Up Outcomes Score‡
Goetzel et al.,32 White-collar/blue- Obesity prevalence Organizational Moderate (n ¼ 4 2y Overall weight 7.0
2010 collar employees/ leadership and sites): reduction in
manufacturing commitment; environmental intensive group;
co./United States coordination HP- prompts, point-of- no effect on
(2431) OHS choice proportion
messaging; overweight,
intensive (n ¼ 5 obese;
sites): specific improvements in
manager biometrics; no
engagement; behavioral
organizational change effects
goal setting;
training and
rewards (3 sites
usual HP)
DeJoy et al.,54 White-collar/blue- Process evaluation Organizational (As above) 4y Environmental 6.0
2012 collar employees/ (implementation, leadership and improvements in
manufacturing fidelity); dose- commitment; high-intensity
co./United States related effects coordination HP- arm; employee
(9 sites) OHS awareness similar
both intervention
Sorensen et Employees/15 Comparing HP with Coordination HP- HP-only arm: 2y No effects smoking, 7.5
al.,36 2002 manufacturing HP-OHS for OHS; coordinated nutrition, tobacco nutrition total
worksites/United smoking management, use sample; blue-
States (7327) cessation; fruit employee HP-OHS arm: collar workers’
and vegetable engagement; nutrition, tobacco smoking
intake comprehensive use integrated cessation quit
program content with health higher in HP-
protection OHS arm (11.8%
programs vs. 5.9%, p ¼
Hunt et al.,53 Employees/15 Comparing HP with (As above) HP-only arm: 2y No differences in 7.5
2005 manufacturing HP-OHS for nutrition, tobacco implementation;
worksites/United smoking use higher reach,
States (7327) cessation; fruit HP-OHS arm: awareness and
and vegetable nutrition, tobacco participation in
intake use integrated HP-OHS arm
with health
* HP indicates health promotion; and OHS, occupational health and safety.
† Based on Sorensen et al.5 Indicators of Integrated Approaches (Table 2, p. S16).
‡ American College of Occupational and Environmental Medicine Practice Guidelines, Harris et al.26

evidence is in the early stages and Organizational-level changes are areas of health and safety systems and
relied on single-group design, pre- valid indicators of the effectiveness of delivery that reflected the intervention
cluding firm causal interpretation integrated approaches,5 and three content, but not other targeted out-
about effectiveness of integrated in- studies (n ¼ 3) assessed organizational comes.46–48 Intervention effects ap-
terventions in targeting safety and health and safety management. Over- peared to cluster around the specific
injury prevention. all, studies reported improvements in organizational elements targeted in

American Journal of Health Promotion September 2017, Vol. 31, No. 5 409
intervention content, rather than gen- grated approaches where all other occupational health were not repre-
eral perceived benefits across func- factors influencing study outcomes sented in the current literature. With
tions. It may be that longer follow-up (study design, setting, sampling, mea- few exceptions,31,38,42 the integration
intervals may detect more distal effects sures, follow-up period) are held con- with on-site medical management or
on organizations over time. Or it may stant. Two studies (four papers) physician care was not widely consid-
be that a more comprehensive focus addressed this aim. Sorensen et al.36 ered or reported. With the exception
on organizational development is and Hunt et al.53 found higher partic- of reports of process evaluations, suffi-
needed if the desired improvement is ipation in the ‘‘intense’’ (integrated) cient details about the organizational
at the level of organizational function- arm compared with the ‘‘moderate’’ management, integration of systems
ing. Interventions that do not specify arm, concluding that for workers who and service delivery, and staff expertise
the integration and delivery of HP, perceive that their exposure to occu- were not reported. Understanding and
safety protection, or medical care and pational hazards is being addressed at evidence about the pathways and
services, for example, are unlikely to the organizational level (intense arm), mechanisms via which integrated ap-
deliver comprehensive successes across willingness to engage in HP is in- proaches are effective is therefore
all organizational functions. creased. Blue-collar employees in the limited.
Promising effects on several indica- intense intervention arm had a near- As the body of evidence grows, meta-
tors of the psychosocial work environ- double smoking cessation rate com- analytic analyses ascertaining the effect
ment, including improved job pared with those in the moderate arm. of integrated interventions in targeting
quality,39 reduced stress,49 and reduced However, in the second intervention specific health outcomes will be possi-
symptoms of depression,41,50 particu- comparing HP with an integrated ble. This will allow for comparison with
larly for those reporting baseline de- approach, no intensity effects were more traditional approaches and for
pression, were reported, although not found against most outcomes, with the more robust conclusions about the
consistently.37,51 The quality of these exception of the worksite observational efficacy and effectiveness of integrated
studies ranged from moderate to high environmental assessment, in favor of approaches. Beyond this, future re-
(score range, 4–8), again suggesting a the integrated intervention.32,54 Fur- search needs to include the develop-
degree of confidence that effects were ther research in this vein is required. ment and implementation of
attributable to the interventions. We acknowledge some limitations to assessments of the type, nature, and
Of the nine studies reporting on our approach. Our study criteria were degree of ‘‘integration’’ at the organi-
various cost-related outcomes, five premised on a definition of ‘‘integrat- zational level.12,57 Future efforts will be
studies reported favorable effects on ed approaches’’ derived from consen- improved by the recent publication of
absenteeism, leave usage, or short-term sus literature. However, we may have standard indicators and metrics to
disability days. The cost avoidance and excluded studies evaluating an inte- assess this.5,13
protection of productivity indicated in grated approach, but with insufficient Integrated approaches have been
these savings per employee are nota- detail in the published paper to estab- posed as comprehensive, efficient so-
ble, particularly because four of these lish eligibility. Our search was not lutions to complex issues. The evi-
studies were of sufficient design quality exclusive to specific outcomes. Target- dence summarized here provides some
to allow for causal interpreta- ed searches pertaining to particular early support for this, showing prom-
tion.28,39,41,52 However, four studies of health conditions may have yielded ising effectiveness particularly for indi-
low to moderate quality reported few more studies than our search strategy vidual employee physical and mental
or no effects on cost out- revealed. Our approach, although it health benefits. Notably, integrated
comes.31,37,43,45 Overall, although precludes consideration or comparison approaches were effective in accessing
some promising evidence exists, the of effectiveness against particular out- sectors of the workforce engaged in
weight of evidence makes it difficult to comes of interest between multiple occupations associated with a high risk
draw firm conclusions about the cost studies, yields an update and overview of accident or injury, with the least
savings or efficiencies of integrated of the effectiveness of integrated in- likelihood of engaging in HP. Impor-
approaches. Plausibly, integrated ap- terventions presented in the scientific tantly, some robust support for cost
proaches streamline organizational literature to date. savings and for the protection of
functions, thereby reducing interven- There are also some limitations to productivity was reported, albeit not
tion costs. However, the studies that the body of literature. Although the consistently, in rigorous process and
compared standard to integrated ap- quality of studies was assessed, signifi- effectiveness evaluations. Higher-level
proaches (Table 5) did not report on cant biases are likely in the literature. organizational benefits were less well
costs savings, so it is not possible to Few studies reported on blinding and assessed or evident in this review.
conclude whether this is the case. concealment, for example, and the Furthermore, it must be noted that
Our second aim was to review studies reporting of other methodologic de- most of the evidence was derived from
where an integrated intervention had tails (attrition, compliance, controlling medium to large enterprises. The
been compared with a more tradition- analyses) were mixed. Incomplete in- applicability and efficacy of integrated
al, or ‘‘health promotion only’’ ap- formation by which to comprehensive- approaches for small to medium en-
proach. This aim allows us to draw ly assess studies and their bias is a terprises need to be confirmed. Given
some early conclusions about the notable limitation. Finally, some key the emerging nature of this evidence
relative strength and efficacy to inte- pathways to integrated approaches to and the variety of intervention targets

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