Good afternoon and welcome to our webinar on Total Worker Health. I'm Dr. Angela Michelide, Vice President of Programs and Education at the American College of Preventive Medicine. The American College of Preventive Medicine is a professional medical society of more than 2,000 physicians dedicated to improving the health and quality of life of individuals, families, communities, and populations through disease prevention and health promotion. Our members are licensed medical doctors or doctors of osteopathy who possess expertise in a broad range of health care skills, including biostatistics, epidemiology, management of health care organizations, research, and the practice of prevention in clinical settings. Our preventive medicine physicians work in a variety of settings, including hospitals, government at the local, state, and national levels, the military, laboratories, business, and academia. I have just a few housekeeping items to share with you. The audience has been placed in listen-only mode. Our recording will be posted in the ACPM Learning Management System if you'd like to share it with friends in a day or so. Please type your questions in the Q&A box and we'll be having a robust discussion at the end of the session. And finally, we'll be emailing you a brief feedback survey after the webinar. So please respond so we can continue to improve our offerings that meet your needs. It now gives me great pleasure to introduce our moderator for today. Dr. James Tocci is the Medical Director and Executive Medical Policy Director of the New York State Workers' Compensation Board. He holds a part-time teaching and clinical appointment at the University of Rochester Medical Center, where he serves as the Program Director for the Preventive Medicine Residency Program and Medical Director of the Travel Medicine Program. He is also an attorney of counsel at the law firm of Barclay-Damon LLP. Dr. Tocci is board certified in both public health and general preventive medicine, as well as in occupational medicine. In addition, he has the honor of being a fellow in both ACPM and ACOEM. Originally from Rochester, New York, Dr. Tocci received his B.S. in biology from Cornell University and his M.D. with distinction from the University of Rochester. He completed his residency training in general preventive medicine and public health at the New York State Department of Health and residency and research fellowship training in occupational and environmental medicine at Harvard University. In addition, Dr. Tocci received his J.D. magna cum laude from the Syracuse University College of Law. Dr. Tocci? Thanks, Dr. McIlyde. I appreciate it. Just one or two other items of housekeeping rules with respect to our agenda today. Dr. Chosewood will be speaking for about 30 or 40 minutes, and we encourage participants to enter any questions that you might have into the chat function, and we will take those questions and we'll answer them all at the end. So don't feel as though you need to save them until the end. We will save 10 or 15 minutes at the end of the presentation to address questions, and again, feel free to send them to us whenever they come up. It's my distinct pleasure today to have been asked by ACPM to moderate this session. Dr. Chosewood and I have had the opportunity to cross paths professionally a few times over the years, but I've been a great admirer of the work that he's done at the Office of Total Worker Health at NIOSH for quite some time now. Dr. Chosewood is the director of the Office of Total Worker Health at the National Institute for Occupational Safety and Health, part of the Centers for Disease Control and Prevention. In this role, he promotes the protection and improvement of the safety, health, and well-being of workers around the world through research, intervention development, and partnerships. Prior to that, from 2004 to 2009, he served as the director of the CDC Office of Health and Safety, helping to safeguard 1,500 members, 15,000 members of the CDC workforce. His office led numerous CDC workforce protection programs, including all occupational health services, laboratory, environmental, and biological safety programs, and workplace well-being and prevention initiatives. Prior to that, he served as the medical director of the CDC's three occupational health clinics. Dr. Chosewood received his MD from the Medical College of Georgia and residency training in family medicine at the University of Connecticut. He has served as assistant professor of family and community medicine at Emory University School of Medicine since 1997. He received an MPH in health policy and management from Emory University Rollins School of Public Health in 2014. Prior to joining the CDC, Dr. Chosewood was the medical director at the tech manufacturing company Lucent Technologies. So without further delay, I will pass the mic to Casey Chosewood. Great. Thanks so much, Jim, and it's great to be with all of you today. I want to thank both ACPM and my colleagues, Jim and Angie, for inviting me to speak with you. I am joining you from our headquarters of CDC in Atlanta, which is where my office is. Our NIOSH headquarters are actually in Washington, D.C., and Dr. John Howard, the director of NIOSH, sends his regards to you all as well. We have quite a beehive of activity here in Atlanta, as you can imagine, with a substantial portion of the CDC workforce obviously engaged in efforts around the global pandemic of COVID-19. We're all hopeful that things are moving in the right direction and day by day things are getting better for the American people as it relates to the pandemic. I will draw some examples and content from our efforts around the pandemic, but largely my job with you today is really to introduce the concept of total worker health or perhaps to expand your view and vision of it if you've already been engaged in the total worker health program. I'm also happy to say that ACPM is one of the 50 NIOSH total worker health affiliates. Our affiliate program is really a learning lab network of partners, implementation, activities, really learning laboratories around the country of real live day-to-day total worker health interventions, and we're really pleased that ACPM has joined us in that effort. So when we talk about total worker health, I sort of want to set the stage to say that it's a lot more than just sort of a plug and play off the shelf product that you might put in place in an employer setting for a workplace well-being or wellness program. I'd like for you to think of total worker health as more a gestalt, a way to interpret and build culture within an organization over the long haul. Total worker health really should be seen as an overarching strategy or an approach for improving the safety, health, and well-being of any workforce or work organization. And we're pretty excited about the uptake that we've seen around the nation using sort of this broad, comprehensive approach to worker safety and health. If you look at the traditional subscribers of NIOSH information, we have been able to expand NIOSH's reach to a different set of audiences than the traditional health and safety audience, folks who are very much interested in sort of this expanded focus of what occupational safety and health can be. I understand that a lot of people on the line today actually practice occupational safety and health or occupational medicine day in and day out, and I certainly want to thank you for both your interest today and also your day-to-day activities for the health of workers around the country. We certainly could not do any of our work without the practitioners who are on the front line in organizations, industries, and workplace settings across the country. Well, on our next slide, just want to sort of set the stage to tell you why work is so influential to our health and well-being. And I didn't say that necessarily work is always bad for our health and well-being. In fact, work sort of is a paradox, if you will, this sort of blend of benefits to our health and potential harms to our health. I think the main takeaway is that work is extremely influential. There are very few things as powerful as a job when it comes to some very important life decisions. For instance, how much money you're going to make. We know that wages are a very strong predictor of health, of longevity, of quality of life, and certainly a job is the key determinant in how much money you make. Where many people work is how they access certain benefits, like healthcare, like certain types of insurance, sick leave, paid leave, an opportunity for retirement, both a savings vehicle or a pension. Those are critical inputs to a person's quality of life. How we commute, where we live, if we get married, if we'll have a dog as a pet versus a cat as a pet. Many of those things are influenced by the job we have. Our relationships in life, strongly influenced by work. Many people say their best friend is a coworker, so it's not all that uncommon. There's also this really tremendous overlap, if you will, between work and the rest of our non-work existence. We're certainly not one work person and a different home person. We carry those challenges back and forth between work and home with us each and every day. In 2020, it's probably an understatement for this past year to say that work and life weren't really inextricably linked. Some people would say unhealthily enmeshed in each other, our work life and our home life. And I think that's been a real challenge. It just, again, goes to show how influential work is to so many different aspects of our health. Work for many people is a strong predictor of longevity as well. So there are lots of reasons why we would want to optimize the work experience, something we spend so much time doing, something that oftentimes is a time sink, if you will, in our overall lives. In fact, one of the greatest detriments to health that a work experience can provide is something that experts have termed time poverty. In other words, I'm so busy with my work, or I have multiple jobs, or long commutes, or have to piece together many different part-time jobs to earn a living wage, that at the end of the work day, whatever that might be, I have no time left over for anything else. And that time poverty robs me of my ability to get enough physical activity, perhaps to shop for and prepare healthier meals, to take care of my loved ones or engage with my family and friends to the extent that I might like to do. So work can be a significant drain on some of those additional resources as well. Let's take a look at the next slide. This is a series of images that just remind us that work can still be quite hazardous. There are a lot of traditional hazards out there that can make work quite deadly. The deadliest catch is one of the most popular TV series, especially in the demographic of men aged 18 to 35. It's in a series called Testosterone Reality. And basically, if you're a man between 18 and 35, these are the types of shows you're watching. Another one, Ice Road Truckers, its tagline is a job to die for. These are just reminders that work like transportation, like cold water fishing, certain types of agriculture, logging, still are quite, quite deadly. In fact, if you are a logger or you work on a cold water fishing vessel, your risk of death from that work is 40 times higher than the average worker. So this is a sort of a traditional safety metric that some work is still hazardous by its very nature and design. But I want us to sort of begin to think a little bit more broadly about the hazards and risks that come from work. And that really is my interest in total worker health, is expanding our conversation about what are some of the hazards that come for both traditional and new and emerging ones, and how can we craft interventions and programs? How can we design higher quality, better work, so that at the end of the day, people have a good experience with their work instead of only thinking of it as something that robs them of time or where they have to trade their health for wages. Those are really not acceptable in the modern scheme of approaching workplace health programs. This next slide is a bit busy, but basically it shows the difference between our perception of risk and what risk actually is that we face. So if you look at everything above sort of the horizontal black line is our perception of risk related to a number of things like risk from mobile phones or an airline accident or a terrorist attack. In fact, that big blue circle above the line there is our perceived risk of a terrorist attack. The same color, tiny little blue dot underneath is our actual risk of that corresponding hazard. So basically everything on the left of the screen shows that we overestimate our risk in certain things. Unfortunately, everything on the right side is where we underestimate our true risks. And you can see the two bold black circles, the very large one underneath it says work all. That's our actual risk from work related injury, illness, and death. But we only perceive our risk to be that small white circle just above. So clearly we underestimate, we vastly underestimate work associated risks that we face day in and day out. That's especially when it comes to motor vehicle accidents, still quite a leading cause of death related to work. Heat illness and heat death, certainly a risk that's underestimated. Cancer and cardiovascular disease as well. On the next slide, I'm going to pose a few questions for you. Can the job I have predict my life expectancy? Certainly to some extent the issues that we've raised in the previous slide sort of asked and answered that to some degree. In fact, we know that something as important as access to healthcare through work-supplied benefits is a strong predictor of longevity, especially in some populations. Hispanic women live 10 years longer with health insurance than in those who do not have it as it relates to a benefit that they have through employment. So this is a significant diminishment of life expectancy when folks don't have adequate access to certain benefits that come from employment. Wages, we talked about certain jobs that you have that make you more prone to disability, certainly diminish life quality and longevity. We also have some understanding for traditional relationships between certain chronic conditions and our work exposures. And perhaps some that are clearly very obvious to you and your line of work, the whole idea of the connection between the work we do and our chances for adverse body mass index measures. Let's take a closer look at that. On the next slide, we also raise another risk factor that's often overlooked, and that's the risk factor that comes from shift work. There's some jobs that unfortunately cannot have the risk factor of shift work taken away. Healthcare is an obvious example. We're talking hours that come from public safety work, like firefighters and police, security guards. And in many settings, manufacturing, package delivery, some of the modern jobs that are growing also involve 24-7, always on, seven day a week, oftentimes work. So shift work we know has some strong association with poor health outcomes, like certain types of cancer, heart disease risk goes up, diabetes, obesity, the risk of violence on the job, much higher if you work at nighttime than if you work in the daytime. And even strokes severity. If you have a stroke as a night shift worker, you fare more poorly than someone who has a day only job. There also tends to be a gradient. Evening workers have higher risk than day workers, and overnight workers have higher risk than evening workers. So there is a gradient factor as well. On the next slide, we also see that work influences critical behaviors that either can add to or take away from our overall health and quality of life. Work influences critical choices around tobacco use, dietary habits, physical activity levels, and many other health behaviors as well. We know that outdoor workers, for example, or those who work independently have higher rates of tobacco use than those who don't. And there are other changes that also come related to our health behaviors depending on the occupation or industry that we work in. The next slide is quite familiar to some of you because it sort of points out which jobs are obesogenic compared to the others. You see some here that are maybe 50, 60% higher on average for rates of obesity with the highest rate of obesity amongst police officers, firefighters, and security guards. Quite shocking when I share that to folks who really haven't looked at this kind of measure before. So what is it about this group of public safety workers, firefighters, police officers, and security guards that would actually predispose them to high rates of obesity? Well, we talked about shift work, right? Shift work is part and parcel of these jobs. In addition to shift work, many of these workers have long hours of work. It's not uncommon for these workers to not work 8 or 10 hours, but 12 hours or 24-hour shifts are not uncommon, especially in firefighters. We also see that many of these workers have multiple jobs. It is not uncommon for workers to have pieced together certain jobs in order to make more money. We know that fatigue and this time poverty issue that we talked about before, when you're so busy with commutes and multiple jobs, you don't have time left over for other health pursuits. These are oftentimes quite stressful jobs. The police in our country are under a significant amount of stress over the past few years. This is not new, but perhaps taking on a different level of additional stressors that these workers face. There's also something known as the stress of constant vigilance that is being searched more and more these days, and it also shows evidence that there's some obesogenic quality to this workplace exposure. So, you know, I've raised a number of issues that could increase the obesity rates among these workers without even mentioning donuts and police, for example. So there's definitely something more than just dietary habits that's underlying some of these trends that we're seeing related to obesogenic working conditions. If you're not familiar with the BCOPS study and the decades of work done by NIOSH in this space with the Buffalo Public Safety Officers, I'd invite you to take a look at that important groundbreaking research. NIOSH also has research ongoing in long haul truck drivers where the obesity rate is not 41% that you see here, but the obesity rate, not just overweight and obesity, but pure obesity rate is more than 70% in long haul truck drivers. And again, it isn't because only obese people sign up for these jobs and go apply for these jobs. Obesity is a take home unfortunate benefit of this type of work. It's really implicating, it's really showing the work design itself, the long hours of work, the fatigue that comes from the work, the wage issues that come from this work, the stress of chronic vigilance, the fatigue, all of these things unfortunately implicate the job itself and its design as obesogenic. Let's take a look at the next slide that really reviews some diseases known to be related to work at least some of the time. And in blue here on this list, you see the attributable fraction based on the percent of the population exposed to the risk factor that's implicated in the disease and the relative risk, the underlying relative risk of that condition in the population. These are divided by cancer and non-cancer. Some would be a surprise and some maybe not so. Mesothelioma, almost 100%, not a big surprise. Pneumoconiosis in general, by definition, 100% related to work. But would it surprise you to know that now increasingly studies shown that up to one in five cases of coronary heart disease, the most common cause of death is implicated related to workplace exposures. And there are some new emerging conditions that are not yet on this list that interest NIOSH strongly. And we're looking at many of these related to our total worker health program. These would include things like depression and anxiety, the risk for suicide and the risk of death from substance use disorders also more and more strongly being implicated related to people's work role day in and day out. This slide shows that it really isn't only the actual physical exposures that we have on the job that are increasing our risk. It's the actual mechanism by which we're employed that also can change the nature of our day in and day out risks related to work. We know that the gig economy leads to more jobs over the course of a lifetime, rapid turnover, and oftentimes a built-in element of insecurity when it comes to wages. In general, gig workers, those who have to piece together multiple jobs, think someone who drives for Uber Eats or delivers packages for Amazon, if they're piecing together numerous jobs or they have periods of employment and unemployment mixed in, they have decreased wages over the course of a lifetime. Our research shows that contingent workers are also more likely to have fewer benefits. They may have less training, and oftentimes temporary workers actually have some of the most hazardous work in the country as well. Jobs certainly in manufacturing and other hazardous industries are populated by about 37% temporary workers. In general, contingent workers in this category face twice the risk of on-the-job injuries compared to traditional workers. They may have less training. They may have less experience. Many of them have no benefits, and in some settings, even workers' compensation benefits are difficult to gain in this kind of setting. You might have heard the saying, my father had one job in his lifetime. I've had six jobs in my lifetime. My kids will have six jobs at the same time. This nontraditional way that people are employed has benefits for some people. Some people like the flexibility and are high earners given this kind of employment arrangement, but unfortunately, the vast majority of folks that are in these nontraditional, less secure, more precarious types of work have fared more poorly in general. The next slide really reminds us of the plight of low-wage workers. These are folks who oftentimes have less decisional latitude, less control over their day, certainly decreased flexibility, more job insecurity. They're more prone to have discrimination on the job and wage theft, and we all know that many of these aspects of their work, including that effort-reward imbalance, really raises the ante when it comes to the hazard of job-related stress. I would also posit that stress is really involved in many of those other atypical and emerging work-related issues that we're just starting to better understand. The issue around heart disease, the issues around depression, anxiety, substance use disorder, and suicide related to difficult work and life circumstances, certainly stress is being implicated more and more in our day-in and day-out research. People who are low-wage workers in this country, we define that as 150% or less of federal minimum wage. It would be workers who make a bit less than $450 or so per week, and it's about one in every three workers in the country would be considered low-wage. The other important takeaway here for total worker health interventions is you may get more bang for your buck and be more impactful and have more success if you intervene with improvements, interventions, health promotion efforts in your organization if you prioritize interventions by wages. So having more robust, more frequent, more intensive programming for lower-wage workers, it is definitely a strategy worth exploring. On the next slide, we just simply give you the basic skeleton definition of total worker health. First of all, it's incumbent that you keep workers safe. You really can't build any additional benefits into a job if people are going home at the end of the day with less health than when they arrived. So that's job number one, keep workers safe so that they go home at the end of the day with the same level of health that they arrived with in the morning. That's what a good company, a quality company, a law-abiding company does. But the best companies, the one that take that next step and add in to a high-quality safety program, policies, practices, and programs that actually grow the health and well-being of their workers, those are the companies that are really getting the total worker health approach and are growing the health of their workers so that those workers, they don't go home with the same level of health. They go home with a greater level of health than when they arrived that morning. And you say, well, wow, that's great for the worker, right? It's great for their family and their communities. They can work longer, they have less likelihood of disability, you save money on healthcare resources, but those workers that went home with more health at the end of the day, they wake up and the next day they go back to work and they bring that level of better health back to the organization. The employer, more engaged, less presenteeism, less absenteeism, less likely to spend healthcare dollars, more attuned to customer service, better coworkers. All of these things are benefits that accrue back to the organization as well. It really is the win-win of the total worker health approach. We're very much interested in this measure of worker wellbeing, and we've sort of captured that as the holistic measure that folks are doing a great job of implementing total worker health. Are you elevating the overall wellbeing, both on the job and off the job of your workforce? We've developed a new measurement tool to look at worker wellbeing, and I'll share that resource with you as I close out today. There are five essential defining elements of total worker health as shown on the next slide. Leadership commitment is important, the design of work, not just the adding in of programs, but actually designing the day in day out job itself to produce health benefits. It's very hard to overcome 8, 10, 12 hours of difficult working conditions just by throwing a lunch and learn on diabetes or hypertension in every now and then, or even just by having an onsite fitness center. You have to look at where the main exposure for the risk is. And in general, it's the content of the work itself that needs to be improved if we want to benefit the most from the total worker health approach. We're all about promoting and supporting worker engagement. We call it the participatory approach. A ton of our research is on the benefits of getting workers engaged in the design development, not only of the work, but of any of those additional policies, practices, and programs that you're adding in. And there are a number of great toolkits on our website that help you move through the participatory approach to design total worker health interventions. When you mix work and non-work health related issues, there is a strong need for confidentiality and privacy. And lastly, the sort of sweet sauce of total worker health is this integration. So yeah, safety's great, health promotion is great, but are there additive synergistic benefits that you get when you integrate those two programs together? Our earliest research and our ongoing portfolio shows that's absolutely the truth. You get not only additive benefits, but synergistic health, safety, and non-work related benefits, personal health related benefits from the total worker health approach. On the next slide is just a listing of some of the policies, programs, and practices. I keep going back to those three Ps. I'll just highlight a few. Safe staffing levels, voluntary and not forced overtime, attention to benefits like paid sick leave. Some of our latest research shows that, especially after injuries, workers are especially vulnerable. And not only is the vulnerability to their own health, but the health of their children and spouse and other family members. It suffers as well after workplace injury. So very potent total worker health intervention is to give extra resources and extra assistance to workers after job related injury or absence. Supportive supervision. Some of our greatest research out of our Northwestern, Portland State, and Oregon Health and Sciences University Center of Excellence for Total Worker Health is all about how supervisors can do a better job of supporting workers through difficult times. Day in and day out, whatever the challenge might be on the job, or in times of really strong challenge like we've experienced this past year. Programs to help workers manage their chronic conditions is also becoming more and more important as workers do earlier in life, unfortunately, get chronic conditions. We also have a research program in our National Center for Productive Aging and Work that looks for, what are the supports that workers need at different phases over the sort of working lifespan? And I think you'll find some of the interventions quite interesting there, and I invite you to take a look at our National Center for Productive Aging and Work. Did you know that the most rapid, fastest growing segment of your workforce are people in their eighth decade of life? Those are workers age 70 to 80, the fastest growing segment of your workforce. The next slide really summarizes total worker health in a graphic called the hierarchy of controls. And those of you with, most of you have quite a bit of strong training in workplace safety, you know that there's a traditional NIOSH hierarchy of controls. We applied that to the total worker health model. Basically, eliminating working conditions that are hazardous is the most important and most powerful intervention at the top. Substituting in those three P's, policies, programs, and practices for existing ones. Redesigning the work environment. And here we mean the physical work environment, the psychosocial environment, the built environment, the diversity and inclusion environment, the benefits environment. All of those are prime areas for improving the environment in which we work day in and day out. Increasing people's awareness of their own health and the connection between their work and their health is next. And lastly, is encouraging personal change. And this is how we would differ quite dramatically from the traditional health promotion program that puts almost all of its emphasis on encouraging personal change. We don't think it's not important. We just don't think it's nearly as impactful and powerful as many of the other elements in the hierarchy of controls. So we'd encourage you to move up the hierarchy as dramatically as you can. In my last few minutes, I'm gonna wrap with a case example that looks at unfortunately one of the major challenges facing our nation today. So on the next slide, we're going to talk a little bit about the substance use disorder epidemic of overdose deaths that the nation is facing. So even before the pandemic hit, the country was already facing an epidemic of drug overdose deaths. It was quickly becoming a leading cause of death in some sectors of our society. And the Total Worker Health Team wanted to take a closer look at this issue and examine how NIOSH could help employers and workers with resources struggling with substance use disorder. On the next slide, you'll see our NIOSH framework to address opioid misuse using the Total Worker Health approach. And we look at identifying those workplace conditions that put people at increased risk for first use or ongoing use of opioids. What are those risk factors and how can we diminish those risks so that we have primary prevention against the risk factor for substance use disorder? How can we protect those workers who must respond in emergency rooms, EMTs, police and firefighters that might face certain risk associated with work in this space? And then lastly, how can we develop better real-time methods for detection and decontamination as needed? The graphic to the right is pretty dramatic. It shows in the red line, unfortunately, the total number of opioid deaths, and it's just skyrocketing after 2011, 2012, if you can see there. And then the blue line is the shrinking number of minutes between opioid-related deaths. So the number of opioid overdoses grew eightfold between 2000 and 2018, and then 90 minutes between deaths in the year 2000 fell to only 10 point... I think it's 10.7 minutes between deaths from opioids in the country in 2019. Really quite stark. On the next slide, we see a graphic that chronicles long-term trends in opioid overdose deaths, and this is a time period over roughly half a generation in the country. Take a look at the darkest blue line. Here we see that age-adjusted death rates for synthetic opioids other than methadone increased comparatively slowly between 1999 and 2013, but then increased dramatically and rapidly between 2013 and 2017. Now, this largely accounts for the vast majority of deaths related to opioids in the country compared to the other risk factors there. This represents a 71% increase per year between 2013 and 2017, and unfortunately, we've seen some of these negative trends continue through 2020 as well. On the next slide, we quickly explore the link between opioids and work. So not having a job is a risk factor for overdose death. Having a bad job, one that doesn't have good employment security, including some of the new employment arrangements, are associated with higher risk for opioid overdose death. Hazardous work that might lead to injury and pain or work that causes chronic pain day in and day out. Some workers report using opioids to actually be able to report to work because they don't have any paid sick leave or benefits to stay home and recover. Good example of that's in construction. We see that reported quite oftentimes. And as mentioned here, there are certain industries and occupations that have much higher risk for overdose death. Again, this is not to implicate workers in those industries. It's a direct result of the nature of that work itself as reflected in many of the elements of this list here. On the next slide, we show some NIOSH work that appeared in the 2018 MMWR that looks at occupational patterns in opioid-involved overdose death. And the proportional mortality ratios were highest in six occupational groups that you notice here, construction, extraction, that would be like mining and oil and gas extraction, food preparation and serving, healthcare practitioners and technical occupations, healthcare support and personal care workers. These all had higher than average risk for overdose death based on the occupation alone when controlling for other factors. If you're a construction worker in this country, your risk compared to the average worker is five to seven times greater of dying from overdose death. The leading cause of workplace fatality in Massachusetts for two years was drug overdose. It was the leading cause of workplace death for two years in the state of Massachusetts. The PMR was also elevated for unpaid or unemployed workers as well. On the next slide, we see this unfortunate collision, if you will, some have called it a perfect storm of COVID-19, substance misuse, SUD, and opioid use disorders. More than 40 states have reported increases in opioid-related mortality through the timing of the pandemic. And social distancing measures that unfortunately may impact those with substance use disorder are quite damaging as well. The isolation, the interruption from their support groups, from methadone clinics, from other treatment resources, the unfortunate circumstances around job loss, all of these things have increased the ante, the risk for substance use disorder and overdose outcomes throughout the pandemic. SAMHSA, and this would apply not only to those with substance use disorder, but the Mental Health Disaster Distress Helpline has seen nearly a 900% increase in calls compared to the same time period a year before the pandemic. But the news is not all bad here. On the next slide, I want to just leave you with some resources that we've put together to help organizations who are trying to intervene for their workers and in their workplaces around recovery and treatment for substance use disorders. We've introduced the phrase workplace-supported recovery in our Total Worker Health Program, and we have web resources that I would love for you to check out on this topic. These include evidence-based approaches to reduce risk factors associated with initiating and using substance uses, important for workplaces to lower the threshold and the barrier for actually identifying there's an issue and seeking care for it, educating and empowering management teams and supervisors so they can have early recognition of issues and intervene in a timely manner, lowering the stigma associated with seeking help, and even with the chronic condition of substance use disorder or opioid use disorder itself. We're trying to send the message that like any chronic disease, opioid use disorder can be treated. It can be managed. These people can get better and return to productive lives with full employment. It is possible. We also believe that workplaces have a vested interest in assisting workers in recovery, in reintegration, in sustained employment and return to work. I have just a few slides left that really move us to another important issue that's only been highlighted from the pandemic. We've all known that there is an existing, even pre-pandemic, physician burnout epidemic in the country. Unfortunately, COVID-19 has led to increasing signs and worry over this issue. About 8% of physicians closed their offices altogether after the pandemic. 71% of physicians reported exhaustion and burnout in 2020. This is compared to about half that number that reported burnout and exhaustion in 2019. A third of respondents of this survey reported general feelings of helplessness. More than a third described their burnout level as eight or higher on a scale of one to 10. One in 10 respondents said they do not feel they are coping appropriately with their current level of burnout. And only one in seven actually has sought or plans to seek help for their level of burnout. The pandemic has highlighted that there's a very real, painful, critical need to reduce the stigma that physicians encounter when seeking help, and certainly steps are necessary to improve people's access to and uptake of mental health services and resources in our own field. On the next slide, we know that it's not only physicians, but all adults are struggling. June 2020 survey of 5,000 U.S. adults showed 40% of U.S. adults reporting struggling with mental health or substance use. A third reporting anxiety and depression symptoms. One in seven started or increased their substance use. One in 10, more than one in 10 seriously considered suicide. Our profession is certainly not immune. Healthcare workers also consistently report stress, anxiety, and depression as a result of COVID-19. Unfortunately, this trend requires some additional attention, both at our individual level, practice level, and national public health level as well. On the last slide here, before we start closing, I'll just show a quick overview of a survey of essential workers. One in four were diagnosed with a mental health disorder since the start of the pandemic. More than half relied on unhealthy habits to get through the pandemic. About a third report their mental health has worsened. Three-quarters said they could have used more emotional support during the pandemic. About three-quarters reported unwanted changes in their weight. Eighty percent reported sleeping disruptions, and 40% reported drinking more alcohol as well. I promised you on the next slide a resource to take away, and you're the first audience that I'm actually sharing with this information with today. Just last week, we released the NIOSH Worker Well-Being Questionnaire. It's the first ever survey to comprehensively measure the well-being of workers. It's 68 items. It takes about 12 minutes to complete, and it really will give a great overview of the well-being of any population that you work with or serve. It can be done at the team level, the organization level, the global level. Any number of measures can be taken, and the good news is it identifies where the well-being challenges are in your workplace and helps you pinpoint or target where those interventions should be directed. I'll close with just a quick comment on the next slide about meaningful work. Work, as I mentioned earlier, can be a source for good or a source for harm, and to the extent that we can make work as meaningful to the people that we serve and work with each day, the odds are we're going to be moving in a right direction. So many of these are key themes to what our total worker health research says is important at crafting a better job. Make the work meaningful. Give it a social purpose. Give folks autonomy and flexibility. Recognize them for their hard work in a number of ways, wages, benefits, attaboy, a thank you, and enhance those personal relationships and positive relationships that can emerge from high-quality work. On our next slide, I mentioned some of our centers of excellence and our affiliates program. We have a vast network and an investment of about $12 to $15 million per year in the research underpinning the total worker health approach. You can find out more about our centers and their portfolios just by Googling total worker health. A next resource on the next slide is a textbook. For those of you who want to teach a course, we would love for you to engage the total worker health textbook. It's really all about the basics, the applied, the lived experiences of companies, organizations, and the latest research on total worker health. And my final slide is really just resources on how you can find out more. We have active Twitter, LinkedIn. We have a great newsletter. Feel free to contact me. I would be more than happy to engage with any of you in your own organizations and programs. So, with that, Jim, I'll turn it back over to you, and I'll say thanks so much for letting me share this time with you all today. It's been a real pleasure. Jim Smith Stacy, first of all, thank you very much for a great talk. I think I'm sure that the folks in the audience, I was taking notes myself in terms of some of those resources, especially the worker well-being questionnaire. I'm looking forward to looking that up, actually. A couple of questions that came up while you were talking. You mentioned early on the somewhat paradoxical relationship, you know, firefighters, police officers, long-haul truckers, those are some of the activities that are the most obesogenic, yet those are folks for public safety reasons who we actually want and require to be the most physically fit. I guess the question is, what are some of the strategies that may have worked best in those workforces or workplace populations? That's an excellent question. You know, someone said, unfortunately, the firefighters in our community are not on calendars, right? I mean, they're not maybe GQ models or the latest examples of as healthy as can be. And it really is this paradox, right? It's really more than just diet and physical activity. They're at play here. Some of the actual elements of the work itself, like the long hours, the multiple jobs, the long commutes, a lot of our public safety officers cannot afford to physically live in the communities they serve. So if we were to really swim upstream and change some of those fundamental elements about supplemental housing for those workers, about changes in wages, changes in the infrastructure in our communities that say we believe that these workers need more support beyond just what they do during the 10-hour, 12-hour shift they have. Altering shift length, paying people more so they don't need second jobs. Those would be other interventions. And the other really important takeaway here is how we introduce physical activity into the work itself, right? That's also in and of itself paradoxical. The vast majority of jobs, including many of the jobs that police officers and firefighters have, build in too much inactivity as a regular part of the work, right? So driving around in patrol cars for very, very long periods of time. We're not implementing a good, healthy mix of physical activity and inactivity in the nature of the design of the work itself, compared to maybe in earlier generations when we had more cops on bikes or cops on foot traffic beats, if you will. So there is a sweet spot to be found between jobs that cause not enough activity and jobs that cause too much. In fact, some of the latest research shows that jobs with too much physical activity, such as heavy lifting all day, or these bursts of short, intense physical activity, they actually raise blood pressure and have other risk factors that may actually cause more harm than good as a result of the physical requirement of the work. So most researchers now that look at this issue of how much activity is enough, call it the Goldilocks principle, building in enough just right amount of physical activity through the design of the job itself so that people are not inactive, but they don't overexert to have other cardiovascular risks that relate to the work. So we clearly need to examine the way we integrate physical activity into some of these sedentary components of jobs that are quite common in public safety. Security guards, almost all of their time is spent seated. And that obviously adds to the inactivity. Those other stressors we talked about, the stress of chronic vigilance, there are certain technologies that can be introduced that will decrease some of those harms. Self-driving vehicles have also an opportunity to intervene. We believe that some studies now in long haul truck drivers that allow them to take their mind off the road, this decrease the constant vigilance, maybe look at, read a book, look at a movie on an iPad while the truck is safely driving itself in some settings will be a way to decrease the stressors that these workers face and hopefully impact their risk for obesity. Great question. There's another question that came into the chat room, which was how can preventive medicine physicians, residents, and interested medical students engage the total worker health sites across the United States? I love that question. As you guys know, we have six centers of excellence around the country. They're all in re-competition now. So in June or July, we will announce the new slate of total worker health centers of excellence for five years of research ongoing. Hopefully some of our existing funded centers will be funded for another cycle. We also hope to fund additional new centers as well. So soon we'll have a list of all those and they do invite regional participation from both practicing physicians as well as residents and students in training. NIOSH also has a network of more than 30 education and research centers that offer advanced training. Six different programs now offer certificates or degrees in the field of total worker health. We're also working to establish a professional society for total worker health professionals. Expect an announcement about that in the next four to six months is probably when that will go live. And it's a way not only for certification, but to continue to grow your knowledge and sort of your skillset when it comes to total worker health interventions. We're also planning a new launch of a journal of total worker health, hopefully in the year to come. And we have our regular symposia where people can engage as well. The last thing I would mention is our affiliates program is really open to any nonprofit organization that would like to learn more and become one of our learning living laboratories. And we have a lot of resources that go to our affiliates, a lot of off cycle meetings when our symposia aren't happening. And we bring our affiliates together for additional intense learning. If you have specific questions about connecting to one of the centers in your area, send me a note and I'm happy to do an introduction. I think we probably have maybe time for at least one, maybe two other questions, but one had to do with stress, anxiety, depression, et cetera. Particularly as you noted, not only president in our society to begin with at fairly high levels, but particularly in the wake of this past year with the COVID pandemic, et cetera. And could you discuss those mental health issues and their behaviors and their impact rather on things such as disability, a degree and duration of disability and absences, not only for the mental health issues, but even for other medical conditions, cardiovascular disease, et cetera, diabetes. Wow, you know, it's an excellent question. And I'm certain all your physicians online realize the intense sort of difficulty that comes from comorbidity of any condition, of any health condition with the overlay of depression or anxiety. And that's certainly been evidence in the past year, as well as in any workplace disability. When you have a depression diagnosis on top of an injury, or if it's the only injury, oftentimes it doubles the time to return to work. It can be one of the lengthiest types of diagnoses when it comes to length of disability and absence from work. So getting the metrics right around mental health intervention in the workplace is critical. It's a huge opportunity for cost savings. We're also showing in our 30 year history of research and workplace stress, a stronger and stronger connection between work design, work stress outcomes, supervisory support issues, and long-term disability. So all those things are connected on a spectrum with workplace stress being a measurable, real exposure that arises from the demands of work and from the lack of supervisory supports. Probably one of the quickest antidotes to intervene is using that participatory approach and giving people more flexibility in how when the ins and outs of their day-to-day work, that flexibility is the best current antidote we have for diminishing workplace stress. I see that Dr. McIlyde has joined us, which is sort of the cue to wrap things up. I could sit and talk about this stuff for the next two hours, but we are time limited. So with that, I'll welcome Dr. McIlyde back into the discussion. Well, thank you, Dr. Tachi for your excellent moderation and to you, Dr. Chosewood for such a inspiring presentation. I agree with you, Jim, that there are so many more questions that we wanna ask to our speaker today. And I hope that our preventive medicine colleagues will get involved in this total worker health movement. It seems as though you've provided us with so many avenues and pathways for involvement. And let's face it, we all are workers and we're all concerned about health. So it's a perfect marriage. I just have a closing slide, and that is to encourage all of you on the call to sign up to attend our ACPM annual conference, which is virtual this year, May 16th through 19th. Please look out for the survey. And for more information, please log on to the acpm.org website for education and events to not only hear an archived version of this recording to share with your friends, but also so many other educational offerings that can help you to earn your CME credits in the future. So with that, I'll say thanks again, and we'll see you soon.

Total Worker Health

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