What is Total Worker Health® (TWH)?

Over the last few years, you’ve inevitably noticed “safety” take on an expanded meaning. We no longer worry about chemical, biological, or ergonomic hazards alone. The safety profession increasingly thinks about the workers’ ability to cope with their role. We increasingly ask things like, “Will my team be able to manage this workload physically and mentally?”

The transition to this wider view of safety is, in part, fueled by NIOSH’s Total Worker Health ® (TWH) program.

What is Total Worker Health, and is it achievable for your organization? Let’s dive into a program you’re going to see much more of in the next two to five years.

What is Total Worker Health®?

With origins dating back to 2003, Total Worker Health® is a NIOSH program formally launched in 2011.

NIOSH defines Total Worker Health as “policies, programs, and practices that integrate protection from work-related safety and health hazards with efforts to promote health and prevent disease for the advancement of worker well-being.”

TWH doesn’t leave everything you know about safety by the wayside. Instead, TWH acknowledges that despite demonstrable improvements in workplace safety, work-related injuries, illnesses, and deaths still happen and figures remain stubborn in industries like construction. 

With TWH, we recognize that there are missing pieces of the safety puzzle that are harder to regulate than exposures. 

We know about chemical hazards and the impact of ergonomic injuries. However, work also influences us in ways that we are increasingly understanding through research. Co-worker interactions, workloads, availability of health benefits and time off, and a worker’s environment and community all impact their safety at work.

In short, TWH goes beyond the SOP, the JHA, and even the work environment. TWC advocates for a worker’s total, holistic environment, including issues otherwise traditionally left to HR.

Total Worker Health Gives a Name to a Recognizable Problem

Whether you are a career safety practitioner or have just landed your first safety job, you’ve probably seen some of the impacts of the issues covered by Total Worker Health first hand.

Here’s a great example of a situation that falls under NIOSH’s view of Total Worker Health.

Let’s say you’re an ASP-certified safety pro at a general contractor. Your company writes safety expectations into every subcontractor’s contract. Plus, you run a robust, digital safety program that makes it easy to raise and resolve hazards and increase accountability for all subcontractors. Everyone works hard; so hard, in fact, that you’re all working long hours with early starts and late finishes to meet deadlines. After all, construction is incredibly competitive, and a combination of labor and material shortages make projected timelines difficult to meet.

Even with your robust safety program and contractual obligations, you’re seeing a lot of near-misses and more injuries than you think you should. 

Within a traditional safety program, you might find yourself at a loss as to what to do next. You’re recording all your hazards, decreasing time to hazard resolution, and building accountability into your contracts and safety program. What’s left?

Total Worker Health asks you to dig deeper. In this case, TWH might ask you to look at the work environment. 

Evidence shows that long hours and shift work can increase workers’ risk for sleep disturbances. If teams aren’t getting enough sleep, then their risk for fatigue-related errors, which might be more unpredictable, goes up. (There’s evidence for this from Caruso (2014) in healthcare and elsewhere.)

At its core, TWH gives a name and a diagnostic tool to something you might have only had a sneaking suspicion about before. Even having a name for it makes it easier to correct or even prevent these issues from creating problems for workers.

Why Total Worker Health? Why Now?

Safety team responding to a preventable incident at work

TWH has been on the minds of researchers, practitioners, and regulators for almost 20 years. So, why are you hearing so much about it now?

In one sense, the COVID-19 pandemic has shone a bright light on what it means to be safe at work. Everyone is taking a serious look at things we can do to protect workers in a way that we haven’t before, including OSHA. When you combine the impetus of the pandemic with the valuable research performed over the last 20 years, it’s clear that not only do we need to do more to support workers but we can. 

TWH isn’t a feel-good program; it’s measurable and actionable.

There’s another reason why your organization should start seriously thinking about TWH. 

Total Worker Health, or a similar standard, could become a mandatory part of your compliance program.

TWH Could Become Enforceable

According to rumblings within the community, regulators are likely looking for ways to someday regulate TWH programs. In a recent episode of the Safety Justice League podcast, safety lawyer Adele Abrams described an OSHA that “remembered there was an “H” for health” in its name.” 

A combination of renewed focus on public health along with clear agendas at OSHA and the Department of Labor could translate into big regulatory changes for you.

Check out the episode here: SJL Presents Ask the Safety Lawyer (What the H?)

We’re already seeing some of this happen on the ground, if only internally. According to a report from the University of Colorado, OSHA regional managers are also taking workplace mental health more seriously and are upskilling with training.

Plus, the American Society of Safety Professionals together with ANSI announced the beginning of a voluntary Total Worker Health management standard. It’s a voluntary consensus standard, yes, but what you’re looking at is a trend picking up speed.

But beyond throwing a new element into compliance and risk management programs, there’s an even better reason to get acquainted with Total Worker Health. That reason is that TWH works.

TWH Works

TWH is still in its infancy, but there’s strong evidence that TWH works to not only promote public health but make safer workplaces.

In a 2015 review of 17 studies on 17 TWH intervention programs, 16 out of 17 saw improved outcomes, including reduced risk factors for injuries and illness as well as a reduction in actual injuries or illnesses. One study even compared an OSH-only program to a TWH+OSH program and found the latter sorely outperformed the former.

In another early review, Hammer and Sauter (2013) found that TWH helped mitigate the negative effects of work-life stress among workers, such as decreased sleep, low levels of exercise, and food choice.

The University of Colorado Department of Environmental and Occupational Health and the Center for Health Work & Environment, one of six Centers of Excellence for TWC appointed by NIOSH, also concluded its Small+Safe+Well (SSWell) study of TWH among small businesses. 

Researchers at the school found that when small businesses rolled out TWH, the businesses elevated the health and safety climate in those companies. Their results even translated across industries and geographic locations.

The evidence is still coming in, but you can read more peer-reviewed articles on TWH for free using Google Scholar or ResearchGate.

TWH is Just Good Business 

Beyond the regulatory issue, TWH (or an acknowledgment of the importance of its fundamentals) is good for workers and good for business. Just as running a safety program produces substantial ROI for any business, so too does going further and investing in TWH.

The CDC and NIOSH provided some excellent evidence on the return on investment of TWH, including:

  • Fewer nonfatal occupational injuries (thus fewer workers compensation claims)
  • Lower costs due to reduced absenteeism
  • Increased loyalty and engagement and thus higher productivity and lower turnover

The total ROI seems to run between $2.05 to $4.61 per dollar invested in Total Worker Health.

We have more evidence than ever about the relationships between worker health and safety and benchmarks like education and training, workplace culture, employee benefits, and equity and accessibility. So, there’s no reason not to start thinking about ways that your organization can start thinking about every employees’ needs and well-being beyond your current obligations.

Total Worker Health vs. Wellness Programs: What’s the Difference?

Safety Pro Completing Self Inspections
Total Worker Health programs are integrated safety programs with measurable attributes

Until recently, protecting employees from workplace hazards and implementing workplace wellness goals have each operated in their own spaces. Risk management or safety teams deal with operational hazards that threaten a worker’s health. HR (where available) or consultants focus on wellness.

NIOSH’s TWH program brings the two together.

TWH does acknowledge employee wellness as a goal, but there are real differences — what’s the real difference?

The first and most pressing differentiator is this: unlike wellness programs, Total Worker Health could become a regulatory requirement. In this way, your TWH program will likely come with specific metrics to meet or outcomes to achieve. Metrics or measurable outcomes may initially look like documented policies, programs, or practices. But with the evolution of technology, these could evolve over time into something more specific. Your TWH requirements will be far stricter than the requirements attached to a traditional wellness program, which is still considered to be a job benefit rather than a regulatory requirement.

A second and very pertinent difference is that TWH is an integrated approach to safety. TWH is part of health and safety; a wellness program can stand on its own. By looking at TWH, you’re acknowledging that long shifts can lead to sleep disturbances and thus to potential incidents. Thus, you’re tying sleep directly to job safety.

While these differences may seem nominal on their surface, they will directly impact the way you create, manage, and report on a TWH program.

Examples of Total Worker Health in Action

So what does TWH look like on the ground? The good news is that its highly adaptable to your organizational needs. But it does touch on some workplace strategies that fall outside the risk manager’s typical role, including:

  • Community supports
  • Compensation and benefits
  • Organization of work
  • Policies
  • Work arrangements
Total Worker Health Issues provided by the CDC/NIOSH

These lists may seem overwhelming, but you don’t have to create TWH policies and programs from scratch. The Oregon Healthy Workforce Center, part of OHSU, recommends using a combination of tools and toolkits to get started.

OHWC’s tools work for team-level changes and the toolkits address organization-level changes.

What Does it Take to Get Started with Total Worker Health Programs?

Every organization has a unique health and safety program. So, it’s no surprise that every business will also have a unique Total Worker Health strategy and programs. These programs are highly contextual, and research shows they perform best when finely attuned to your workers’ needs.

Some of the factors impacting your program will include:

  • Industry type and industry vertical
  • Business type
  • Physical location
  • Number and type of employees

Remember that Total Worker Health is a method for integrating your safety program; it’s not a blueprint that you can copy and paste. You’ll run your program according to the five defining elements of Total Worker Health.

NIOSH recommends getting started with the Fundamentals of Total Worker Health® Approaches, which include an introduction to the five defining elements of Total Worker Health. It also includes self-assessments, action plans, and general program planning.

What are the 5 Defining Elements of Total Worker Health?

Total Worker Health is all about policies and programs. It also comes with five elements:

Per NIOSH, the five defining elements of TWC include:

  1. Demonstrate leadership commitment to worker safety and health at all levels of the organization
  2. Design work to eliminate or reduce safety and health hazards and promote worker well-being
  3. Promote and support worker engagement throughout program design and implementation
  4. Ensure confidentiality and privacy of workers
  5. Integrate relevant systems to advance worker well-being

The Fundamentals of Total Worker Health® Approaches PDF walks you through each of these elements in detail.

Getting Started: Total Worker Health Resources

We just covered a lot of information, and by now, you should have a better idea of TWH’s aims and the principles behind it. But it can still look like a huge undertaking.


The good news is that there’s a lot of resources out there for you to get started with planning for and building your TWH program.

We recommend starting here:

You can also get more resources from NIOSH-designated TWH Centers of Excellence. These centers complete TWH research that will help you better understand both what TWH looks like and how effective it can be:

Looking to add to your safety certifications? You can complete a Certificate in Total Worker Health with the University of Colorado.

TWH Could Transform Workplace Compliance

Total Worker Health is just around the corner, so the time to start thinking in terms of worker wellbeing is now. The good news is that there’s already a substantial body of resources and research aimed at helping small and middle-market businesses maximize the possible TWH benefits.

Just like safety, TWH comes with an ROI for businesses and workers alike. It could also transform not only your workplace compliance program but also the way your organization does business.

Stay tuned to the Safesite blog and our social media channels for more Total Worker Health how-tos and free Total Worker Health templates.

Team Safesite

By Team Safesite

We're a group of safety and tech professionals united in our desire to make every workplace safer. We keep a pulse on the latest regulations, standards, and industry trends in safety and write about them here on our blog.

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