December 4, 2020

A 2020 study that sets the stage for a Total Worker Health® approach has been named Paper of the Year by the International Journal of Behavioral Nutrition and Physical Activity.

The paper, which shares the results of a first-of-its-kind randomized controlled trial that lasted for five years, is titled, “Results of caring and reaching for health (CARE): a cluster-randomized controlled trial assessing a worksite wellness intervention for child care staff.”

Dr. Dianne Stanton Ward

Dr. Dianne Stanton Ward

Dr. Laura Linnan

Dr. Laura Linnan

The work was co-led by Dianne Stanton Ward, EdD, FTOS, FACSM, professor of nutrition, and Laura Linnan, ScD, senior associate dean of academic and student affairs, professor of health behavior and director of the Carolina Collaborative for Research on Work and Health — both faculty members at the UNC-Chapel Hill Gillings School of Global Public Health.

Child care workers are among the lowest paid workers in the United States, and they face a variety of health concerns. Caring for children presents near-constant physical and mental demands, and employer provided health insurance is very rare in child care settings.

Linnan and Ward’s Caring and Reaching for Health (CARE) study evaluated a 6-month Healthy Lifestyles intervention that targeted child care workers’ physical activity along with other health behaviors and the overall workplace health environment. More than 550 child care workers at 56 unique facilities were assigned to either the Healthy Lifestyles intervention group or the Healthy Finances control group.

As part of the Healthy Lifestyles intervention, the researchers provided in-person workshops, in-center informational displays and magazines, electronic messaging and an interactive website; they also coached child care center directors on how to support staff. They measured the workers’ physical activity using wearable trackers, and they measured final results through health and fitness assessments, health behavior surveys and workplace environmental audits.

After six months, moderate-to-vigorous physical activity had declined slightly in both arms of the study. While the Healthy Lifestyles intervention was based on promising pilot studies, it did not improve physical activity, which was the primary hoped-for outcome.

Why, then, is this the Paper of the Year in a high-impact international journal? The results confirmed the pressing need to focus on the social determinants of health as integral to the overall health of child care workers.

“What is astonishing about our selection as Paper of the Year is that we had null findings on the primary outcome,” Linnan explained. “Typically, those studies are hard to get published. We are pleased that there were some encouraging results — workers in the Healthy Lifestyles intervention did slightly improve their diet and lowered their smoking rates. But the real takeaway is the need to emphasize the larger social factors that make it difficult for essential child care workers to be more physically active — factors like demanding work schedules, high levels of stress. low pay and exposure to infectious diseases at work.”

The researchers say that future interventions should focus on prevalent health issues like obesity and stress; should include both high-tech and high-touch intervention strategies; and should address work conditions and other social determinants of health — like wages — as a means of improving the health of these essential workers.

“Child care workers report being very tired at the end of the day, having limited [free] time and facing a number of competing after-work responsibilities,” the co-authors wrote. “Any single or combination of these reasons may explain why the intervention did not produce intended improvements. Results of this study and similar recent workplace trials suggest that improving workers’ health will require a more comprehensive approach that addresses not only health behaviors but also the work environment, working conditions, benefits and compensation.”

With this paper, Linnan, Ward and their co-authors have set the stage for future research that moves beyond traditional health promotion efforts and applies a Total Worker Health® approach. Total Worker Health® addresses issues of individual workers and the overarching conditions of work that contribute to poor health.

The Gillings School currently offers a graduate certificate in Total Worker Health®, which trains students from diverse disciplines to understand the changing nature of work, how work influences health, how to engage with workers to plan, deliver and evaluate programs, policies and practices at work, and how to work as part of an interdisciplinary team of safety and health professionals to protect and promote workers’ health through comprehensive workplace interventions.

One such Total Worker Health® study is already underway: Linnan and co-lead researcher Leena Nylander-French, PhD, CIH — professor of environmental sciences and engineering at the Gillings School and director of both the Occupational Exposure Science and Industrial Hygiene Program and the North Carolina Occupational Safety and Health Education and Research Center — recently received $485,895 through the North Carolina Policy Collaboratory.

That funding supported the launch of a technical assistance program called Carolina PROSPER, which is helping small and medium-size N.C. businesses stay open or re-open in a safe and healthy way using a Total Worker Health® approach.


Contact the UNC Gillings School of Global Public Health communications team at sphcomm@unc.edu.

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