Integrating Power Into Research, Outreach, and Practice to Make the Most of the Next Decade of the Total Worker Health® Program
Year: 2025
Type: article
Abstract: BACKGROUNDCME Learning Objectives After completing this enduring educational activity, the learner will be better able to: Outline the root causes of why the field of Total Worker Health, occupational safety, and health more broadly has been unable to achieve some of its own goals Discuss the idea of power and power relations in the workplace and society Discuss the need for regulatory changes to advance TWH The Evolution of Total Worker Health® The National Institute for Occupational Safety and Health’s (NIOSH) Total Worker Health (TWH) program’s vision is to “protect the safety and health of workers and advance their well-being by creating safer and healthier work.”1 In January 2024, the NIOSH personnel Chosewood and colleagues published an editorial in this journal2 in which they stated “all work should both be safe and enhance the health and well-being of workers” (p.6, emphasis added). They furthermore highlighted next steps for the TWH program in advancing toward that vision, stating that the program will emphasize “...issues that have previously existed on the periphery of occupational safety and health research, practice, and policy and yet play a significant role in worker well-being. These evolving issues include confronting concerns like the ever-increasing wage gap; gender, racial, and ethnic inequalities; invasive monitoring and AI-related losses of workers’ agency and autonomy; employment insecurity; and occupational segregation and oppression, all of which may lead to adverse physical health outcomes as well as raise risks for workplace stress and mental health disorders.”2 (p.7, emphasis added). The Need for Power Awareness To our minds, these seemingly peripheral concerns have a common origin in imbalances in the power that equip some with the means to achieve their desires over—and indeed, at expense of—the desires of others. We also contend that power imbalances are thus the reason that all work is neither equally safe nor likely to promote health or well-being. Work in its current configuration both mirrors and enacts social patterns that create unsafe and unhealthy workplaces, and it is thus unlikely that hazards to safety and health can be effectively eradicated without attention to the power disparities that support those patterns. Moreover, theory about health promotion posits that in order to enhance health and well-being, individuals must perceive their experience of the world as reasonable, something they can manage, and involving roles that are consequential.3 Power imbalances inherent in contemporary work arrangements deny many workers control over the conditions under and in which they offer their labor, making it unlikely that they experience employment in a way that promotes their health. These imbalances will continue until power can be redistributed more equally to allow working people greater governance over the work experience. Following from this logic, we believe that increased and explicit attention to power imbalances is crucial to achieving NIOSH’s vision of work as a source of health and well-being. The perspective that power imbalances must be addressed to fully realize the potential health benefits of work might register as idealistic to many in the occupational and environmental health community. Perhaps this is true. But an alternative vision is often the first step toward catalyzing change.4 For those interested in this ideal, we offer some guidance on how we might begin to incorporate perspectives on power into work on occupational health. We first briefly introduce several fundamental concepts that have informed and broadened our understanding of the forces that shape worker well-being. We then highlight some assumptions that an engagement with power allows us to challenge in service of realizing NIOSH’s goal of decent work for all. We conclude by applying these ideas to a contemporary situation (silicosis among artificial stone workers) challenging worker health, highlighting how greater engagement with power-related concepts would facilitate the elimination of this problem. Conceptual Levers: Social Causation of Health, Power, Power Relations, and Power Consolidation The prevailing biomedical model assumes that causes of ill health are (1) limited to biological, chemical, and physical exposures, (2) related to specific bodily malfunctions, (3) understood through (natural) experimentation and statistical comparison, and (4) effectively mitigated through technological innovations within medicine and engineering.5 This perspective underpins health and safety regulation as well as prevention and curative medical practice. As such, the biomedical model has an obvious role to play in protecting workers from specific threats and in limiting their impact. However, it is difficult to see how the biomedical model, alone, can advance worker well-being or confront work-related structural arrangements that result in health inequalities, because these things are beyond its purview. To supplement the biomedical model, we recommend the social model of health and illness. Social models have evolved from nineteenth century social movements to explain population patterns of health and ill-health that persist despite seismic advances in medicine and engineering. These models recognize that the more immediate causes (the “proximal” or “downstream” causes) of ill-health that constitute the primary focus of the biomedical perspective are heavily influenced by relations between and among people and the institutions and systems in which they are embedded (the “distal” or “upstream” causes). These institutions and systems, as well as the associated values and beliefs, shape peoples’ experiences and what is possible for them, in and beyond work.5–9 In social understandings of health, distal/upstream causes such as power relations and consolidation are not only included, they are necessary components of inquiry and preventive action. Work is one context in which power and power relations shape organizations and experiences.10 In terms of organizations, power can be defined as the asymmetric control over valued resources (eg, money, decision-making control, influence) that can be distributed positively (reward) or negatively (punishment).11–14 Power may be understood as a relative lack of dependence on others to access resources, the possession of resources, or both that stem not from an individual person’s attributes,10 but from one or more bases of power. French and Raven15,16 conceptualized these power bases that represent asymmetries: expert power (special knowledge), reward power (being able to provide rewards), information power (having the resource of information), legitimate power (position-based power), referent power (based an individual’s status), and coercive power (power as a result of the ability to provide punishment). Occupational safety and health (OSH) professionals will likely recognize these bases of power in how a line supervisor or employer may draw from them to exercise their power over workers within an organization, and understanding these dynamics provides useful insight into how individual worksites can develop more health-supportive distributions of power. In many ways, the organizational level is also a microcosm of how power is attained and distributed at the societal level to shape work. Societal-level power, however, is perhaps more apparent in the concept of power relations. Power relations refers to the relative power between segments of the population. Work is source of direct economic resources as well as other health-enhancing resources (eg, medical care, safety). These resources are differentially distributed across the population, and prevailing power relations render resources more or less necessary, valuable, and useful to population subgroups.6 Disempowered groups are less likely to be able to access work that provides adequate economic and health-enhancing resources, which in turn increases negative health consequences as a result of the unaffordability of the necessary ingredients for good health (eg, nutritious food, quality and timely medical care, convalescence, etc). Furthermore, discrimination resulting from systemic sexism, racism, and ableism (among others) hinders how far those resources go, effectively reducing the resources available. Finally, consistently disempowered social groups are less able to use resources in service of their health because the experiences of powerlessness sap their will to effectively apply such resources in the service of health promotion.6 In other words, those who have more power relative to others determine who gets what and how far it goes in improving health. Consider foreign-born Latino workers, among whom access to health-enhancing resources is limited by employment insecurity, low wages, increased risk of injury and illness in the workplace, and limited access to medical care owing to immigration status, language barriers, and lack of medical insurance. This disparity reflects social power relations that establish employment conditions and terms that disfavor these workers relative to others. Lack of resources and the vitality and effectiveness to use them diminishes both individual health and well-being as well as the capacity to act toward meaningful change. When resources are scarce, people have less energy, time, and knowledge to come together to consolidate power and pressure institutions to mount responses to problems that challenge their well-being.17 American history demonstrates time and again that organized actions are necessary to consolidate power to address social inequity and harm, whether they occur in the workplace or community. We need look no further than the landmark legislation related to worker rights, health, and safety and the agencies created to further them, or to legislative and administrative gains in civil rights, all of which were pushed by the collective actions of everyday people. Leveraging Power-Related Concepts to Challenge Assumptions that Hamper Efforts to Improve Worker Health In our collective, varied experiences in understanding and advancing worker health, safety, and well-being, we have encountered some assumptions, many of which are implicitly present rather than consciously articulated, which strike us as hampering efforts to support workers. In what follows, we lay out several of these assumptions and tie them to ideas of power in order to demonstrate the utility of doing so for change making. Assumption 1: That the optimal focus for change making is on workers (rather than on work and the forces that shape work). In a workplace, individual workers have few bases of power and little to no ability to control resources. With most workers possessing little power, they are limited in their ability to make meaningful changes to their employment or working conditions or to effectively utilize resources that support their health and well-being. However, much OSH research and practice focuses on workers rather than work and the forces that shape work. This assumption can result in attribution of injury or illness to failure of the worker to comply with some work practice or policy or to manage boundaries between work and broader life effectively. This can further represent a bias about which workers are deserving of decent work, demonstrating a power relation that disempowers workers. On a practical level, this assumption naturally results in an emphasis on training to encourage better health and safety behaviors. However, the root causes of health and safety risks are more complex than the action of any specific individual and thus must be the solutions. In this assumption, the lack of focus on the social structures that create the conditions of employment and work means both often stay the same.7 As a result, the creation and application of health-related interventions focused on workers are less effective, in part because worker agency is often limited to a narrowly defined scope. Such interventions must also occur continuously as workers change through aging and other demographic shifts. By changing work, we are not depending on specific individuals to teach, adopt, or accept changes. Assumption 2: Enhancing the well-being of workers can be achieved by ensuring that specific employers or organizations minimize/eliminate workplace hazards and promote worker well-being. Within workplaces, employers have more power bases and resources than workers.18 Regulatory schemes, such as the US Occupational Safety and Health Act, reflect this power by requiring employers to provide a place of employment “free from recognized hazards…” (OSHA Act Section 5). Employers, however, are also able to consolidate power within their industries, with suppliers, and with others, which provides them with an outsized ability to determine conditions of work. Consider noise in the workplace. Employers exercise their power within the workplace when choosing whether to rely on workers wearing hearing protection or to purchase quieter equipment to prevent noise-induced hearing loss. They can also use their consolidated power to define hearing protection as the industry-normative practice and prevent regulation that requires use of quieter equipment instead. Such decisions are often driven by financial interests, and it will require a change in power relations to shift or overcome this financial calculus. Without this change, workers and OSH professionals will not have the leverage to fully eliminate or control known hazards, let alone move into the territory of health and well-being enhancement. As we note above, our well-being depends in part on whether we experience of the world as reasonable, manageable, and meaningful.19–21 Worker voice, or “the capacity of workers to speak up, articulate, and manifest collective agency that ultimately improves the terms and conditions of their employment and their livelihood,” and “shaping the societies in which they live”22 (p.4) facilitates this experience and increases the chance of achieving well-being. Assumption 3: That treating work as a social cause of health and health inequalities means ignoring hazards in a specific workplace. Because employment and working conditions result, either indirectly or directly, from measures determined by powerful actors in cultural, legal, political, and economic spheres, efforts to address hazards in a workplace must occur in parallel with efforts to address these social causes of health and health inequalities. At present, hazards exist and pose risks to workers because their persistence is either tacitly or actively permitted by larger societal forces. For example, there is a social tolerance for injury, illness, and death among worker groups marginalized in our society (eg, “someone needs to do this dangerous job, better them than me”). Or, to put it plainly, health is socially created5 and thus must be socially addressed. When the workplace is the sole focus in efforts to improve worker health, this can produce a reactive rather than precautionary approach to workplace hazard identification and management. Focusing on workplaces in tandem with attention to how societal-level power relations are made manifest (eg, regulatory policies), however, allows for the identification of root causes and the ability to prevent a hazard from ever occurring. Looking beyond specific jobs, workplaces, or industries allows us to see the commonalities in hazards and, therefore, where lies the power to change them. In the fields of epidemiology and public health, this sort of root causes analysis is described as moving upstream. The following parable makes clear why it is essential. “There I am standing by the shore of a swiftly flowing river and I hear the cry of a drowning man. So I jump into the river, put my arms around him, pull him to shore and apply artificial respiration. Just when he begins to breathe, there is another cry for help. So I jump into the river, reach him, pull him to shore, apply artificial respiration, and then just as he begins to breathe, another cry for help. So back in the river again, reaching, pulling, applying, breathing and then another yell. Again and again, without end, goes the sequence. You know, I am so busy jumping in, pulling them to shore, applying artificial respiration, that I have no time to see who the hell is upstream pushing them all in.”23,24 Assumption 4: That occupational safety and health professionals with a specific technical focus are ill-suited to the tasks of promoting health and well-being and informing broad-based policies relevant to, but not targeting, workers in specific industries, occupations, or jobs. The most apparent power base of OSH professionals is expert power, but, in truth, OSH professionals have many power bases in a workplace and in society both, and can use their individual power and consolidated power across the profession to engage with policies that support worker health and well-being. OSH professionals may feel most authoritative in the areas of work and for but this can with to and The a where a workplace health for which OSH professionals obvious power to Assumption That any is better than no to work, but many lack the power to decent work. has that is to health, but also that the in health between those with employment and no employment is the health of workers by them to recognized hazards and and more that their ability to or improve their health. When an illness or injury results in a worker may further be to the and access to what resources they were able to from Assumption That employer well-being will into worker well-being. Employers have power to resources that can advance worker health and well-being, but are to employer that the economic to the employer to or with a regulation are employer from workers’ or However, the to workers and their are the power Moreover, OSH professionals that to improve worker health are yet many have of despite economic to the In workplace often on the that employer and worker well-being are such that to employer well-being (eg, financial will result in to worker well-being (eg, of However, is it to that employer into which might this not be to to Assumptions of has among workers who stone of in described these workers as foreign-born Latino who this work in These workers develop because they of the and of the which can as much as The of research about focuses on risk such as the of the and effectiveness of control Such information is to but the also to power-related issues that have for what people will do with the These have been described as a population of foreign-born workers who lack adequate medical Such a implicitly the attention to of workers rather than the institutions and systems that make those relevant to their lack of protection and support and their to These workers need and to work, but their often and perhaps without for them to work in less likely to have protection and and further put them at increased risk of wage this power likely requires change in employment for workers and attention to larger societal forces such as and racism, because such forces Latino those who are into that we allow to more dangerous than others and 5). The of stone reflects the power of and to create and a that is low and despite the of a hazard and that requires and tasks known for to pose risks to workers. by to eliminate or from the may lead to of less recognized hazards that may not be recognized until workers This situation reflects the power of and with an in or to define work, and requires us to challenge the of and on and consolidate power so as to for worker health and well-being the of and The by some to the of stone in line with that in will but not eliminate and health focus on changing implicitly a with and or another is better for health than no 5). that research has that the of hazard and control both from to employers and employers to workers, has been and workers are likely to be without power to the hazards by current and stone Finally, the has many and employment and work This situation hinders regulatory and medical and who is for a workplace of recognized of has been to employers and the use of control which either eliminate or move them further step would be to the role of conditions that make risk and for creating and to include such in our research, and such that is where it and will continue to require stone with are focus only on the by a worker in a and them with medical and for will improve the health and well-being of that why this work the way it however, will to power to improve the health, safety and well-being of workers across the and more broadly across work of models of social health and ideas related to power will facilitate greater of issues that on the TWH program’s vision of work that is of safety, health, and well-being for all workers.
Institutions: University of California, Los Angeles, University of Utah
Language: English
Subfield: Occupational Therapy
Field: Health Professions
Domain: Health Sciences
Open Access status: green
Award: G5958440925
OpenAlex ID: W4407179202