摘要：Chronic disease is the leading cause of death in the United States. Risk factors and work conditions can be addressed through health promotion aimed at improving individual health behaviors; health protection, including occupational safety and health interventions; and efforts to support the work–family interface. Responding to the need to address chronic disease at worksites, the National Institutes of Health and the Centers for Disease Control and Prevention convened a workshop to identify research priorities to advance knowledge and implementation of effective strategies to reduce chronic disease risk. Workshop participants outlined a conceptual framework and corresponding research agenda to address chronic disease prevention by integrating health promotion and health protection in the workplace. Approximately half of Americans live with a chronic disease, and about one fourth report residual effects from it. 1 Chronic diseases, including heart disease, cancer, and stroke, are the leading cause of death in the United States. 2 Disparities in chronic disease occur by race and ethnicity and by socioeconomic status, with minorities and lower income groups having a higher prevalence of heart disease, cancer, and stroke and multiple risk factors for these conditions. 3 – 5 Of additional concern is that the prevalence of chronic disease is higher in the United States than in other developed countries. 6 – 8 More than 81 million Americans have cardiovascular disease, at an estimated cost of $503 billion in 2010. 9 In 2005, more than 1.3 million people were diagnosed with cancer, with costs in 2007 estimated at $219 billion. 10 Almost 24 million people have diabetes, at a cost of $174 billion in 2007. 11 Approximately 67% of adults are overweight or obese, 12 with a projected cost of $147 billion for 2008. 13 In addition, nonfatal chronic conditions, such as musculoskeletal disorders 14 and psychological disorders, 15 are major sources of disability. 16 Worksites provide a venue to address multiple individual risk factors and risk conditions through worksite health promotion aimed at changes in individual behaviors, worksite health protection including occupational safety and health interventions, and efforts to address unhealthy work-family conflict. 17 , 18 As a venue for delivering chronic disease prevention efforts, worksites provide a ready channel for reaching the large segment of the population that is employed. Worksite conditions also contribute to the development of chronic diseases, for example, through hazardous job exposures, high job demands, and inflexible work schedules. Individual health behaviors contribute significantly to chronic disease outcomes. In 2000, 435 000 deaths (18.1% of total deaths) were attributed to tobacco use, 365 000 deaths (15.2%) were attributed to a combination of poor diet and lack of physical activity, and 84 000 deaths (3.5%) were related to misuse of alcohol. 19 , 20 These 4 individual health behaviors collectively accounted for approximately 40% of all deaths in the United States in 2000. 21 Worksite health promotion is an effective way to enhance health-promoting behaviors, reach a large segment of the population, and reduce chronic disease risk factors. Comprehensive worksite health promotion has been recommended by the American Heart Association, the American Cancer Society, Healthy People 2010, the National Institute for Occupational Safety and Health, the National Institutes of Health, and the Centers for Disease Control and Prevention (CDC). 22 – 25 In 2006, US health care spending was reported to be more than $2 trillion, 26 and employers on average paid more than one third of this cost. 27 A meta-analysis of the literature on costs and savings associated with worksite health promotion programs indicated that medical cost reductions of about $3.27 are observed for every dollar invested in these programs. 28 This figure has been corroborated by recent systematic reviews and economic analysis conducted by the Task Force on Community Preventive Services, which reported an annual savings of $3.20 for every dollar invested. 29 , 30 Other benefits of worksite health promotion include reduced absenteeism 28 , 30 and improved employee attitudes toward work. 31 The work environment, encompassing the physical, psychosocial, and organizational environments, directly shapes employee health, safety, and health behaviors. 22 In 2008, more than 5000 workers died from occupational injuries, 32 and work-related illnesses account for 49 000 deaths annually. 33 More than 4.6 million workers experienced nonfatal occupational injuries or illnesses in 2008, about half of which resulted in time away from work because of recuperation, job transfer, or job restriction. 34 Employers and insurers spent approximately $85 million in workers’ compensation costs in 2007, 35 although this figure is only a portion of the costs associated with work-related illness and injury that are borne by employers, workers, and society overall. In 1992, the total economic costs to the United States from occupational illnesses and acute injuries was estimated to be between $155 billion 36 and $171 billion, 37 figures that are similar to those for all cancer or all cardiovascular disease in this time period. 36 , 38 Worksite health protection initiatives include efforts to improve occupational safety and health, address organizational factors at work that influence worker health, and support work–life balance. Compliance with safety and health standards was mandated by the passage of the Occupational Safety and Health Act of 1970. Occupational Safety and Health Act rules, such as those pertaining to cotton dust, inorganic lead, and blood-borne pathogens, have resulted in reduced exposures and illnesses. 39 Efforts by government, labor, management, and health professionals have also led to reductions in exposure to biomechanical risk factors at work that contribute to work-related musculoskeletal disorders, the most common category of occupational disease reported to the Occupational Safety and Health Administration. 14 Labor–management health and safety committees and workers’ compensation insurers have reported that the Occupational Safety and Health Administration's support of prevention through regulation and training have contributed to the prevention of work-related injuries and illnesses. 40 Worksite initiatives can possibly redress sources of stress at work, including inflexible work schedules, low job control, and excessive job demands, 41 , 42 that lead to negative health outcomes for employees and their families. Integrating health behavior change programs with work environment changes may be synergistic and enhance their effectiveness. 22 , 43 Beyond using the worksite as a platform to promote changes in individual health behaviors, such as smoking, dietary intake, physical activity, and weight control, a more integrated approach recognizes that the workplace acts as both an accelerator and a preventer of chronic disease and is a key determinant of individual health behaviors through physical, social, organizational and psychosocial mechanisms. Simply stated, workers may perceive changes in their individual health behaviors to be futile in the face of significant occupational exposures that have considerable bearing on their health. Conversely, management and labor efforts to create a healthy work environment may contribute to workers’ motivations to modify their personal health behaviors, and they may foster a climate of trust that supports workers’ receptivity to their employer's messages regarding individual health behavior change. 44 – 46 This principle of integrating worksite health protection with worksite health promotion was recently endorsed by the American Heart Association for cardiovascular health promotion. 47 The National Heart, Lung, and Blood Institute; the National Institute of Occupational Safety and Health; the CDC; the National Institute for Child Health and Human Development; and the National Cancer Institute convened a workshop to identify research needed to develop effective programs to reduce chronic disease risk and to support worker and family health by effectively promoting healthy and safe individual behaviors; reducing physical, psychosocial, and organizational risks at the worksite; and promoting work–life balance. The workshop, held May 21 and 22, 2009, was cochaired by Barbara Israel, professor of health behavior and health education in the School of Public Health, University of Michigan, and Glorian Sorensen, professor of society, human development and health at the Harvard School of Public Health. The panel, selected by the workshop sponsors to reflect a range of perspectives on chronic disease prevention in the workplace, consisted of specialists in epidemiology, sociology, occupational and preventive medicine, organizational psychology, occupational health psychology, health education and health behavior, environmental and occupational health, economics, exercise physiology, ergonomics, pediatrics, and human development. Their interests were varied and included individual behavior and organizational change research, family and community health research, public policy, intervention design and evaluation, translation and outcomes research, participatory action research, and health disparities (roster available as a supplement to the online version of this article at http://www.ajph.org .). The workshop objective was to develop a comprehensive and coordinated research plan to build the evidence base for effective chronic disease prevention for working adults and their families through worksite interventions. To achieve this objective, the workshop had 3 main informational sessions: promoting individual behavior change, changing the work environment (physical, psychosocial, and organizational), and intervening to influence the work–family community interface. Each session was guided by 8 areas of discussion: research strategy, current state of the science, conceptual models, research design, practices and policies, cost-effectiveness, barriers, and specific populations. We present 3 parallel worksite approaches to preventing chronic disease—promoting individual behavior change, changing the work environment, and addressing work–family community interface—and explore opportunities for coordination and integration of these approaches.
