A Systematic Review of the Literature on Health and Wellness Coaching: Defining a Key Behavioral intervention in Healthcare

Affiliations.

  • 1 Duke Integrative Medicine, Duke University Health System, Durham, North Carolina and Department of Psychiatry and Behavioral Science, Duke School of Medicine, Durham, NC, United States.
  • 2 Duke Integrative Medicine, Duke University Health System, Durham, North Carolina and Duke School of Nursing, Durham, United States.
  • 3 Department of Exercise and Sport Sciences, School of Health Science and Human Performance, Ithaca College, Ithaca, NY, United States.
  • 4 Working Together For Health, Boston, Massachusetts, United States.
  • 5 Duke Integrative Medicine, Duke University Health System, Durham, North Carolina, United States.
  • 6 Integrative Health Consulting and Coaching, LLC, Scranton, Pennsylvania, United States.
  • 7 Institute of Lifestyle Medicine, Department of Physical Medicine and Rehabilitation at Spaulding Rehabilitation Hospital, Boston, Massachusetts, United States.
  • 8 Duke School of Nursing, Durham, United States.
  • PMID: 24416684
  • PMCID: PMC3833550
  • DOI: 10.7453/gahmj.2013.042

Abstract in English, Chinese, Spanish

Primary objective: Review the operational definitions of health and wellness coaching as published in the peer-reviewed medical literature.

Background: As global rates of preventable chronic diseases have reached epidemic proportions, there has been an increased focus on strategies to improve health behaviors and associated outcomes. One such strategy, health and wellness coaching, has been inconsistently defined and shown mixed results.

Methods: A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-guided systematic review of the medical literature on health and wellness coaching allowed for compilation of data on specific features of the coaching interventions and background and training of coaches.

Results: Eight hundred abstracts were initially identified through PubMed, with 284 full-text articles ultimately included. The majority (76%) were empirical articles. The literature operationalized health and wellness coaching as a process that is fully or partially patient-centered (86% of articles), included patient-determined goals (71%), incorporated self-discovery and active learning processes (63%) (vs more passive receipt of advice), encouraged accountability for behaviors (86%), and provided some type of education to patients along with using coaching processes (91%). Additionally, 78% of articles indicated that the coaching occurs in the context of a consistent, ongoing relationship with a human coach who is trained in specific behavior change, communication, and motivational skills.

Conclusions: Despite disparities in how health and wellness coaching have been operationalized previously, this systematic review observes an emerging consensus in what is referred to as health and wellness coaching; namely, a patient-centered process that is based upon behavior change theory and is delivered by health professionals with diverse backgrounds. The actual coaching process entails goal-setting determined by the patient, encourages self-discovery in addition to content education, and incorporates mechanisms for developing accountability in health behaviors. With a clear definition for health and wellness coaching, robust research can more accurately assess the effectiveness of the approach in bringing about changes in health behaviors, health outcomes and associated costs that are targeted to reduce the global burden of chronic disease.

主要目标: 审查同行评审的医 疗文献中所发布医疗和健康辅导 的操作性定义。方法: 在系统性审查和 Meta 分析首选报告项目 (PRIMSA) 指 导下进行的医疗与健康辅导医学 文献的系统性审查,可编辑与辅 导干预指定功能和教练背景和培 训有关的数据。成效: 通过 PubMed 初步识别 出八百篇摘要,并最终纳入 284 篇全文文章,其中 多数 (76%) 为实证性文章。 文献指实施医 疗和健康辅导为完全或部分以患 者为中心 (86% 的文章)、包含 患者决定的目标 (71%)、合并自 我发现和积极学习流程(63%)(与 较为被动地接受建议相比)、鼓 励对行为负责 (86%)、 并配合 辅导流程向患者提供某种类型的 教育 (91%)。此外,78% 的文章 指出,辅导是在与接受过特定行 为改变、 沟通和激励性技能培 训的教练建立了一贯、持久的关 系的情况下提供 结论:尽管先 前在如何实施医疗与健康辅导方 面存在分歧,但通过本系统性审 查,发现在医疗与健康辅导的定 义方面达成一种共识;即,医疗 与健康辅导是一个由拥有不同背 景的医疗专业人员交付的、以行 为改变理论为基础、以患者为中 心的流程。该实际的辅导流程促 致患者决定目标设定,鼓励除内 容教育以外的自我发现,并且将 多种机制整合在一起,用以发展 健康行为的问责制。有了明确的 医疗与健康辅导定义,人们便可 开展大量研究,更为准确地评估 该等方法在健康行为、健康结果 和相关费用方面所带来变化的有 效性,从而减轻全球的慢性疾病 负担。

Objetivo principal: revisar las definiciones operativas de la formación de salud y bienestar según las publicaciones en la literatura médica revisada por pares.

Fundamentación: Dado que que las tasas mundiales de enfermedades crónicas evitables han alcanzado proporciones epidémicas, se ha hecho cada vez más hincapié en las estrategias para mejorar las conductas sanitarias y los resultados asociados. Una de estas estrategias, la formación de salud y bienestar, se ha definido de forma inconsistente y ha mostrado resultados mixtos.

Métodos: Una revisión sistemática, guiada por los elementos de información preferidos para las revisiones sistemáticas y el metanálisis (PRIMSA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses), de la literatura médica sobre la formación de salud y bienestar permitió la recopilación de datos sobre las características específicas de las intervenciones de formación, y sobre la procedencia y la formación de los formadores.

Resultados: se identificaron inicialmente ochocientos resúmenes a través de PubMed y, en última instancia, se incluyeron 284 artículos con texto completo. La mayoría (76 %) eran artículos empíricos. La literatura aportó una definición operativa de la formación de salud y bienestar como un proceso que está total o parcialmente centrado en el paciente (86 % de los artículos), que incluye metas determinadas por los pacientes (71 %), incorpora procesos de aprendizaje activo y descubrimiento personal (63 %) —en comparación con una recepción más pasiva de asesoramiento—, alienta la responsabilidad por las conductas (86 %) e imparte algún tipo de educación a pacientes junto con el uso de procesos de formación (91 %). Además, el 78 % de los artículos indicó que la formación se presenta en el contexto de una relación continua y coherente con un formador humano que está capacitado en aptitudes motivacionales, comunicativas y de cambios conductuales específicos.

Conclusiones: A pesar de las divergencias en la forma en que la formación de salud y bienestar se ha puesto en marcha con anterioridad, esta revisión sistemática señala un consenso emergente en lo que se refiere a la formación de salud y bienestar, es decir, un proceso centrado en el paciente que se basa en la teoría del cambio conductual y que se administra por parte de profesionales sanitarios con diversas experiencias en el pasado. El proceso real de formación implica el establecimiento de objetivos determinado por el paciente, estimula el descubrimiento personal, además de la formación en contenidos, e incorpora mecanismos para desarrollar la responsabilidad en las conductas de salud. Con una definición clara de la formación de salud y bienestar, la investigación sólida puede evaluar de una forma más precisa la eficacia de la estrategia en la consecución de los cambios en las conductas de salud, los resultados sanitarios y los costos asociados dirigidos a reducir la carga mundial de la enfermedad crónica.

Keywords: Systematic review; behavior change; behavioral intervention; coaching; health; wellness.

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Sport and Quality of Life pp 11–27 Cite as

The Conceptions of Quality of Life, Wellness and Well-Being: A Literature Review

  • Marco Ciziceno 8  
  • First Online: 20 April 2022

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Part of the Social Indicators Research Series book series (SINS,volume 84)

In the last few years, a growing body of research has been interested in wellness, quality of life, and well-being issues. Furthermore, institutions, governments, and policymakers start to introduce numerous physical and mental well-being programs, whereas scholars interested in well-being research use different indicators to evaluate them. Although these terms are popular in the scientific debate, they are variously interpreted and at the conceptual level do not have a standard definition. This disagreement is particularly relevant when considering the questions related to their measurement and application in empirical research. This review explores the main theoretical conceptions of quality of life, wellness and subjective well-being in the current scientific literature.

  • Quality of life
  • Subjective well-being
  • Life satisfaction

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Ciziceno, M. (2022). The Conceptions of Quality of Life, Wellness and Well-Being: A Literature Review. In: Corvo, P., Massimo Lo Verde, F. (eds) Sport and Quality of Life. Social Indicators Research Series, vol 84. Springer, Cham. https://doi.org/10.1007/978-3-030-93092-9_2

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Rethinking mental wellness among adolescents: an integrative review protocol of mental health components

  • Zaida Orth   ORCID: orcid.org/0000-0002-2895-0417 1 &
  • Brian van Wyk   ORCID: orcid.org/0000-0003-1032-1847 1  

Systematic Reviews volume  11 , Article number:  83 ( 2022 ) Cite this article

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Adolescents have been overlooked in global public health initiatives as this period is generally considered to be the healthiest in an individual’s life course. However, the growth of the global adolescent population and their changing health profiles have called attention to the diverse health needs of adolescents. The increased attention toward adolescent health has accentuated existing gaps as global health reports have emphasised that there is a continued need for valid and reliable health data. In this context, evidence has shown that mental health issues constitute one of the greatest burdens of disease for adolescents. This integrative review aims to unpack the meaning of mental wellness among adolescents and its associated constructs by analysing and synthesising empirical and theoretical research on adolescent mental wellness. In doing this, we will develop a working definition of adolescent mental wellness that can be used to develop an instrument aimed at measuring adolescent mental wellness.

The integrative review is guided by the five steps described by Whittemore and Knafl. A comprehensive search strategy which will include carefully selected terms that correspond to the domains of interest (positive mental health/mental wellness) will be used to search for relevant literature on electronic databases, grey literature and government or non-governmental organisations (NGO) websites. Studies will be included if they describe and/or define general mental wellness in adolescent populations aged 10–19. The screening and reporting of the review will be conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data from the integrative review will be analysed using narrative framework synthesis for qualitative and quantitative studies.

This integrative review aims to search for and synthesise current research regarding adolescent mental wellness to identify how wellness is being described and conceptualised. We aim to identify gaps and to contribute to a more comprehensive definition of mental wellness which can aid in the development of an age- and culturally appropriate measure of adolescent mental wellness.

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In 2016, adolescents (10–19 years) were estimated at 1.2 billion (18%) of the world population, making them the largest population of adolescents in history [ 1 , 2 ]. Adolescents have been largely overlooked in global health and social policies, because this period is generally considered to be the healthiest in an individual’s life-course [ 2 ], and the unique health problems associated with adolescence have been misconstrued or ignored in favour of more pressing public health concerns [ 3 ]. However, changing health profiles of adolescents in both developed and developing countries have called attention to the diverse health needs of adolescents [ 1 ]. According to the World Health Organization (WHO), more than 1.1 million adolescents died in 2016—mostly from preventable or treatable causes [ 4 ]. Therefore, the considerable gains from global investments in child and maternal health programmes would yield fewer long term benefits without simultaneous investments in adolescent health [ 5 , 6 ].

According to the life course approach, all stages of an individual’s life are intricately intertwined and interconnected with each other, and other people in society including past, present and future generations of their families [ 7 ]. In other words, evidence has shown that early life experiences, including events experienced in the  pre-conception phase, play a role in determining the developmental origins and trajectories of health and wellness or disease across an individual’s life course [ 7 ]. From this perspective, it is understood that the health and wellness of individuals, as well as communities, depend on interactions oscillating between multiple risk and protective factors throughout one’s life. Based on this, early and appropriate interventions during child and adolescent years are shown to be the most effective prevention strategies to promote optimal public health and human development [ 5 , 6 , 8 ]. Additionally, following the life course approach, it is argued that these early investments in child and adolescent health will yield a triple dividend as they will grow into healthier adults who can contribute positively to society, as well as the health and development of the next generation [ 2 , 9 ].

Globally, mental health issues constitute one of the greatest burdens of disease for adolescents. According to the WHO, in 2016 mental health conditions accounted for 16% of the global burden of disease and injury for adolescents, with depression being identified as one of the leading causes of illness and disability, followed by suicide as the second leading cause of death in adolescents and self-harm the third [ 4 , 9 ]. UNICEF propagates that half of all lifetime mental disorders have onset during adolescence [ 10 ]. The recent inclusion of adolescents on the global health agenda as a target group for intervention represents a key step toward reducing the global burden of disease attributed to mental health disorders and reducing preventable deaths [ 2 , 10 , 11 , 12 , 13 ]. However, due to the previous neglect of mental health as a public health issue, efforts to address adolescent mental health are met with various challenges.

Currently, there is a lack of data concerning mental health conditions among adolescents, especially those living in low- and middle-income countries (LMICs) [ 11 ]. The lack of a body of quality evidence can affect the way adolescents are represented in national policies, as well as the ways in which government and healthcare officials respond to treatment and prevention [ 2 , 14 ]. According to WHO, a 2014 review of health policy documents from 109 countries showed that 84% have given some attention to adolescents, with three-quarters of them addressing sexual and reproductive health; one-third addressing tobacco and alcohol use, and one-quarter focusing on mental health [ 1 ]. In LMICs, efforts to improve child and adolescent mental health services (CAMHS) are hindered by a lack of specific CAMHS policies, resources and, fewer child and adolescent psychiatrists and other mental health professionals [ 12 , 13 ]. Furthermore, studies from developed countries have suggested that while CAMHS and policies are in place, there is a lack of mental health service uptake among children and adolescents due to various attitudinal, stigma-related, and structural barriers to accessing mental health services [ 14 ]. These challenges and barriers to CAMHS in both LMICs and higher-income countries are particularly apparent among adolescents living with a chronic disorder or disease [ 15 , 16 ]. Mental health conditions are increasingly recognised in children and adolescents with chronic disorders. Studies have shown that living with a chronic health condition is associated with increased risk of developing comorbid physical and mental health problems, which in turn influence treatment adherence and quality of life [ 16 , 17 , 18 ].

Another recurring obstacle for integrating mental health into global public health initiatives and frameworks is the lack of consensus of a definition of mental health [ 19 ]. Despite the growth of mental health and wellness research in recent decades, the question of how mental wellness should be defined remains largely unresolved [ 20 ]. This has given rise to broad and ambiguous definitions which, consequently, result in concepts such as mental health, mental wellness and mental wellbeing being used interchangeably. Currently, the term ‘mental health’ is often used as a euphemism to refer to mental illness, referring to conditions that adversely affect cognition, emotion and behaviour (i.e. depression and anxiety) [ 21 ]. This use reflects in the literature as the majority of adolescent mental health research adopts the dominant pathological view of health by focusing on mental health disorders such as psychiatric disorders, general mental health disorders, emotional and behavioural problems and psychological distress [ 22 , 23 ]. Similarly, global health initiatives such as AAH-HA! focus majorly on the burden of disease of mental disorders by reporting on self-harm, depressive disorders, childhood behavioural disorders and anxiety [ 3 ]. This dominant pathological view of mental health persists despite the contributions of positive health and wellbeing research which argues that wellness and illness are not two ends of the same continuum as previously thought, rather these constructs represent two independent continua [ 19 , 23 ]. In other words, the absence of mental illness does not necessarily indicate a state of mental health/wellness [ 1 , 23 , 24 ]. Therefore, it is imperative to consider both mental wellness and mental illness in research, and to move away from the previous ‘absence of disease’ model to one that emphasises positive psychological functioning for mental health [ 23 , 24 ]. In this model, wellness refers to the degree one feels positive about life, and one’s capacity to manage one’s feelings, behaviours, and limitations [ 23 ]. From this model, addressing adolescent mental wellness is seen as more than treating and mitigating the burden of disease of mental illness, rather it is also useful in maintaining lifelong mental and physical wellness and preventing the development of mental disorders [ 23 ]. Adolescents in particular experience multiple physical, social, and emotional changes, which can positively or negatively impact on their mental wellness. Therefore, interventions at this stage are crucial as research shows that providing psychosocial support and mental health promotion, such as psycho-education and community empowerment, facilitates the development of mental wellness (positive mental health) which is protective against psychopathology (mental illness) [ 9 , 24 ].

There is a need to develop accurate and culturally appropriate measures of mental wellness to support research endeavours that aim to improve adolescent mental health. Therefore, there is a greater necessity to clarify what is being measured, and how the resulting data from the measure should be interpreted to undertake fair and valid assessments. As such, developing a definition of mental wellness should encompass more than the description of wellness itself (as is the case with current definitions) to a clear and definite statement of the exact meaning of the construct.

To this end, this integrative review forms part of a larger study which aims to unpack the meaning of mental wellness among adolescents and its associated constructs by analysing and synthesising relevant literature and empirical and theoretical research on adolescent mental wellness. In doing this, we aim to use this information to develop and conceptualise adolescent mental wellness as a construct. Additionally, by focusing on conceptualising mental wellness, we hope to provide clarity regarding the way concepts such as mental wellness are used in the literature by clearly distinguishing between mental health (as a euphemism for mental illness) and mental wellness as a positive state of mental health. We aim to develop an instrument which can measure mental wellness as an indicator of general mental health and wellness among adolescents.

Methodology

The integrative review has been identified as a unique tool in healthcare for synthesising investigations available on a given topic or phenomena and for directing practise based on scientific knowledge [ 25 ]. The existing body of literature on mental health among adolescents is varied and complex as there are many concepts associated with mental health research ranging from positive aspects such as ‘resilience’ and ‘self-efficacy’ to negative aspects such as ‘depression’ and ‘anxiety’. As such, it is not possible for one study to capture all the dimensions associated with mental health. However, by adopting the integrative review method, we will be able to include the various sources and methodologies used in research to summarise existing empirical and theoretical literature associated with [positive] mental wellness concepts to better understand and conceptualise mental wellness among adolescents. The integrative review method proposed by Whittemore and Knafl [ 26 ] will be used: (1) problem identification, (2) literature search, (3) data evaluation, (4) data analysis, and (5) presentation of the integrative review.

Problem identification

The problem identification stage is a crucial first step in an integrative review. Therefore, we aim to approach this as a phase in itself. This means, going beyond the initial research questions to fully develop a framework of the problem and all its related variables. In this section, we describe some approaches we will use to identify the problem which the integrative review will address. As previously mentioned, our interest lies in understanding how mental wellness is conceptualised among adolescents, to aid in the conceptualisation and development of a mental wellness instrument for adolescent populations. Based on our initial reading of the literature, we have identified two recurring issues in this regard: firstly, there is a lack of validated mental wellness instruments for adolescents; and secondly, despite a growing body of research, the question of how mental wellness should be defined remains largely unresolved. Based on this, we have proposed to follow two research questions to aid us in identifying the problem.

How is the concept of mental wellness defined in research involving adolescents?

What indicators of mental wellness are being explored/investigated in research?

These two questions allow us to investigate how research has approached the study of mental wellness, what variables were of interest and how these were defined. To answer these questions, we will follow an iterative approach to gather and assess the available information to present a clear identification of the problem and all the variables of interest. To this end, we are currently conducting a systematic review of mental health instruments used in research with adolescent populations [ 21 ].

Understanding how mental wellness has been defined in research is an important part of our problem identification, as it will show us what theories and/or definitions of mental wellness are dominant, and which are missing. As Dodge et al. [ 20 ] argued, current definitions of wellness are more descriptive in the sense that they describe aspects of wellness rather than the construct itself. This lack of definition poses a problem in measurement development as the definition of a construct ultimately influences how it is being measured and how the resulting data should be interpreted. Therefore, to further aid our problem identification, we will compare the data from the systematic review with data from qualitative interviews exploring mental wellness among adolescents living with HIV (ALHIV). As previously mentioned, this review forms part of a larger study aimed at developing an instrument to measure mental wellness among adolescents. We have chosen to include the interviews with ALHIV for the problem identification stage as we want to develop an instrument that can measure mental wellness among healthy populations and those living with a chronic illness such as HIV. This is necessary as Manderscheid et al. [ 23 ] argue that a dual emphasis on mental and physical health is essential as studies have shown that positive health may influence biological functioning. This information will be used to identify the problem of the integrative review (Fig. 1 ). Using the information from the problem identification phase, we will move on to the second phase to conduct a literature search of mental health concepts used in research with adolescent populations.

figure 1

Steps followed to identify the problem for an integrative review

Literature search

A comprehensive search strategy which will include carefully selected terms that correspond to the domains of interest (mental health/mental wellness) will be used to search for relevant literature on electronic databases, grey literature and government or non-governmental organisations (NGO) websites. A systematic database search will be performed using Ebscohost (Psycharticles, Academic Search Premier, SocIndex), Educational Resource Information Center (ERIC), Medical Literature Analysis Retrieval System Online (MEDLINE) and Sabinet. A list of initial keywords has been identified for the search strategy: ((adolescen* OR teenage* OR young people OR youth) [AND] (“psychological wellbeing” OR “mental health wellbeing” OR “mental wellness” OR “mental health”). As the integrative review allows for a more iterative process, the list of keywords will be modified as the initial search reveals more relevant and refined search terms.

Inclusion and exclusion criteria

Studies will be included if they describe and/or define mental wellness in adolescent populations. As the interest lies in conceptualising mental wellness for adolescents, only studies dealing with general mental health, wellbeing and wellness will be included. In other words, studies focused on mental disorders or mental illnesses among adolescents will be excluded. For this review, studies will be included for all adolescents aged 10–19 who have not been diagnosed with a mental illness or disorder. Eligible studies will include qualitative, quantitative, and mixed-method studies published from 2000 to 2022. The time period of the search strategy was chosen due to the paucity of research in this area [ 3 , 22 , 27 ]. Furthermore, the prioritization of adolescent health and the focus on adolescent-friendly services occurred after 2000 [ 28 ].

Screening and selection process

Study selection.

The PICOT mnemonics (Table 1 ) for reviews will be used to guide study selection.

The above-mentioned criteria and search strategy will be used to search the databases. The screening and reporting of the review will be conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline and checklist [ 29 ]. The number of hits for each database will be recorded and the citations will be exported to Mendeley citation software. Following this, two reviewers will screen all the titles and abstracts to assess which articles are appropriate for inclusion. The full-text articles of the included abstracts will be downloaded and reviewed again to determine which articles should be included for the final assessment [ 30 ]. Any discrepancies between the two reviewers will be resolved by a third party. Additionally, based on the information retrieved from the screening, the researcher may modify the search to include other relevant sources.

Data evaluation

In this integrative review, the primary sources will include both empirical and theoretical literature - which increases the complexity of evaluating the quality of the included sources [ 26 ]. According to Whittmore and Knafl [ 26 ], integrative reviews using diverse sampling frames may adopt an approach to data evaluation that is similarly used in historical research. In this case, the authenticity, methodological quality, informational value, and representativeness of the available sources should be discussed in the final report. To minimise bias, the two reviewers will utilise two existing quality criteria instruments to evaluate the different types of data [ 26 ]. Firstly, the Mixed Methods Appraisal Tool (MMAT) (Additional file 1 : Appendix A) will be used to assess the methodological quality of the studies as it allows for summarising the overall quality across a range of study designs [ 31 ]. Secondly, the SFS scoring system version E (Additional file 1 : Appendix B) will be used to assess the quality of the methodologies of the included articles [ 32 ]. The SFS scoring system version E is appropriate as it allows for screening of both quantitative and qualitative research and allows for the appraisal of the definitions of constructs being investigated [ 32 ].

Data analysis

Once the selection of included articles has been finalised, we will extract the relevant data into a Microsoft Excel document to organise the information and prepare for the data synthesis. The Excel sheet will include information regarding the purpose of the study, study characteristics, results, and appraisal of the study as well as any other supporting information. All data will be cross-checked for quality purposes.

Data from the integrative review will be analysed using narrative framework synthesis for qualitative and quantitative studies. Framework synthesis begins with a tentative framework that can either be borrowed from previous studies or can be developed from key concepts [ 26 , 33 ]. With framework synthesis, the included studies are coded according to the developing framework in an iterative process until the body of evidence can be presented coherently.

In the final stage, the findings from the review will be discussed and presented in either tabular or diagrammatic form. Additionally, the limitations of the review will be discussed as well as recommendations for future research.

This integrative review aims to synthesise current literature on adolescent mental wellness to identify the ways in which this is being described and applied in research. The purpose of this is to identify gaps and to contribute to the conceptualisation of a more comprehensive definition of mental wellness which can aid in the development of an age- and culturally appropriate measure of adolescent mental wellness. Such measures are much needed in adolescent health research as it may be used to better understand the mental wellness needs of adolescents and contribute to the development of interventions and programmes aimed at improving psychological wellbeing and/or mental wellness of adolescents.

Strengths and limitations

According to our knowledge, this protocol describes the first integrative review to investigate and describe how mental wellness is defined in research among adolescents. Understanding how mental wellness among adolescents has been conceptualised is necessary to identify what are the strengths and limitations of such definitions. This will allow researchers to rethink what mental wellness means to adolescents and how this can and should be measured in research. A limitation of this study is related to the search strategy, notably around the time span (2000–2022) and the identification of grey literature, as not all possible sources of literature may be accessed.

Availability of data and materials

Not applicable.

Abbreviations

Adolescents living with HIV

Antiretroviral therapy

Child and Adolescent Mental Health

Low- and middle-income countries

Mixed Methods Appraisal Tool

SFS Scoring System

United Nations International Children’s Emergency Fund

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Acknowledgements

ZO is supported by the National Research Foundation, grant number (118160). Additionally, the authors would like to acknowledge funding form the Belgian Development Cooperation, through the Institute of Tropical Medicine Antwerp. Any opinion, finding and conclusion or recommendation expressed in this material is that of the authors and not the funders.

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ZO conceived the idea, developed the research question and study methods, and contributed meaningfully to the drafting and editing; she also approved the final manuscript. BvW aided in developing the research question and study methods, contributed meaningfully to the drafting and editing, and approved the final manuscript.

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Additional file 1: appendix a..

Mixed Methods Appraisal Tool (MMAT). Appendix B. SFS Scoring System (Version E). Appendix C. PRISMA-P Checklist.

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Orth, Z., van Wyk, B. Rethinking mental wellness among adolescents: an integrative review protocol of mental health components. Syst Rev 11 , 83 (2022). https://doi.org/10.1186/s13643-022-01961-0

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Key influences on university students’ physical activity: a systematic review using the Theoretical Domains Framework and the COM-B model of human behaviour

  • Catherine E. B. Brown 1 ,
  • Karyn Richardson 1 ,
  • Bengianni Halil-Pizzirani 1 ,
  • Lou Atkins 2 ,
  • Murat Yücel 3   na1 &
  • Rebecca A. Segrave 1   na1  

BMC Public Health volume  24 , Article number:  418 ( 2024 ) Cite this article

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Metrics details

Physical activity is important for all aspects of health, yet most university students are not active enough to reap these benefits. Understanding the factors that influence physical activity in the context of behaviour change theory is valuable to inform the development of effective evidence-based interventions to increase university students’ physical activity. The current systematic review a) identified barriers and facilitators to university students’ physical activity, b) mapped these factors to the Theoretical Domains Framework (TDF) and COM-B model, and c) ranked the relative importance of TDF domains.

Data synthesis included qualitative, quantitative, and mixed-methods research published between 01.01.2010—15.03.2023. Four databases (MEDLINE, PsycINFO, SPORTDiscus, and Scopus) were searched to identify publications on the barriers/facilitators to university students' physical activity. Data regarding study design and key findings (i.e., participant quotes, qualitative theme descriptions, and survey results) were extracted. Framework analysis was used to code barriers/facilitators to the TDF and COM-B model. Within each TDF domain, thematic analysis was used to group similar barriers/facilitators into descriptive theme labels. TDF domains were ranked by relative importance based on frequency, elaboration, and evidence of mixed barriers/facilitators.

Thirty-nine studies involving 17,771 participants met the inclusion criteria. Fifty-six barriers and facilitators mapping to twelve TDF domains and the COM-B model were identified as relevant to students’ physical activity. Three TDF domains, environmental context and resources (e.g., time constraints), social influences (e.g., exercising with others), and goals (e.g., prioritisation of physical activity) were judged to be of greatest relative importance (identified in > 50% of studies). TDF domains of lower relative importance were intentions, reinforcement, emotion, beliefs about consequences, knowledge, physical skills, beliefs about capabilities, cognitive and interpersonal skills, social/professional role and identity, and behavioural regulation. No barriers/facilitators relating to the TDF domains of memory, attention and decision process, or optimism were identified.

Conclusions

The current findings provide a foundation to enhance the development of theory and evidence informed interventions to support university students’ engagement in physical activity. Interventions that include a focus on the TDF domains 'environmental context and resources,' 'social influences,' and 'goals,' hold particular promise for promoting active student lifestyles.

Trial registration

Prospero ID—CRD42021242170.

Peer Review reports

Physical activity (PA) has a powerful positive impact on all aspects of health. Regular PA can prevent and treat noncommunicable diseases [ 1 , 2 ], build resilience against the development of mental illness [ 3 ], and attenuate cognitive decline [ 4 ]. Given these pervasive health benefits, increasing participation in PA is recognised as a global priority by international public health organisations. Indeed, a core aspect of the World Health Organisation’s action plan for a “healthier world” is to achieve a 15% reduction in the global prevalence of physical inactivity by 2030 [ 5 ].

Despite international efforts to reduce physical inactivity, university students frequently do not meet the recommended level of PA required to attain its health benefits. Approximately 40–50% of university students are physically inactive [ 6 ], many of whom attribute their inactivity to unique challenges associated with university life. For many students, the transition to university coincides with new academic, social, financial, and personal responsibilities [ 7 ], disrupting established routines and imposing additional barriers to the initiation or maintenance of healthy lifestyle habits such as regular PA [ 8 ]. Students’ PA tends to decline further during periods of high stress and academic pressure, such as exams and assignment deadlines [ 9 ]. This pattern has been observed across diverse university populations and cultural contexts [ 10 , 11 , 12 ], highlighting the importance of understanding the factors that contribute to physical inactivity among this cohort globally.

Understanding the barriers and facilitators to PA in the context of the university setting is an important step in developing effective, targeted interventions to promote active lifestyles among university students. A recently published systematic review found that lack of time, motivation, access to places to practice PA, and financial resources were primary barriers to PA for undergraduate university students [ 13 ]. A corresponding and complementary synthesis of the facilitators of PA, however, has not yet been conducted. Such a synthesis would be valuable in enabling a comprehensive understanding of the factors that influence students' PA and identifying facilitators that could be leveraged in intervention design. Furthermore, applying theoretical frameworks to understand barriers and facilitators to PA can guide the development of theory-informed, evidence-based interventions for university students that purposely and effectively target factors that influence their participation in PA.

The Theoretical Domains Framework (TDF) [ 14 , 15 , 16 ] and the COM-B model of behaviour [ 17 ] are two robust, gold-standard frameworks frequently used to examine the determinants of human behaviour. The TDF is an integrated framework of 14 theoretical domains (see Additional file 1 for domains, definitions, and constructs) which provide a comprehensive understanding of the key factors driving behaviour. The TDF was developed through expert consensus, synthesising 33 psychological theories (such as social cognitive theory [ 18 , 19 ] and the theory of planned behaviour [ 20 , 21 ] and 128 theoretical constructs (such as ‘competence’, ‘goal priority’, etc.) across disciplines identified as most relevant to the implementation of behaviour change interventions. Identifying the relative importance of theoretical domains allows intervention designers to triage which behaviour change strategies should be prioritised in intervention development [ 22 , 23 ]. The TDF has been widely applied by researchers and practitioners to systematically identify which theoretical domains are most relevant for understanding health behaviour change and policy implementation across a range of contexts, including education [ 24 ], healthcare [ 25 ], and workplace environments [ 26 ].

The 14 TDF domains map onto the COM-B model (Fig.  1 ), which is a broader framework for understanding behaviour and provides a direct link to intervention development frameworks. The COM-B model posits that no behaviour will occur without sufficient capability, opportunity, and motivation. Where any of these are lacking, they can be strategically targeted to support increased engagement in a desired behaviour, including participation in PA. Within the COM-B model, capability can be psychological (e.g., knowledge to engage in the necessary processes) or physical (e.g., physical skills); opportunity can be social (e.g., interpersonal influences) or physical (e.g., environmental resources); and motivation can be automatic (e.g., emotional reactions, habits) or reflective (e.g., intentions, beliefs). The COM-B model was developed through a process of theoretical analysis, empirical evidence, and expert consensus as a central part of a broader framework for developing behaviour change interventions known as the Behaviour Change Wheel (BCW) [ 17 ].

figure 1

The TDF domains linked to the COM-B model subcomponents

Note. Reproduced from Atkins, L., Francis, J., Islam, R., et al. (2017) A guide to using the Theoretical Domains Framework of behaviour change to investigate implementation problems. Implementation Science 12, 77.  https://doi.org/10.1186/s13012-017-0605-9

Using the TDF and COM-B model to understand the barriers and facilitators to university students’ participation in PA is valuable to inform the development of effective evidence-based interventions that are tailored to address the most influential determinants of behaviour change. As such, this systematic review aimed to: a) identify barriers and facilitators to university students’ participation in PA; b) map these factors using the TDF and COM-B model; and c) determine the relative importance of each TDF domain.

Study design

The systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [ 27 ]. The review protocol was registered on PROSPERO (CRD42021242170).

Search strategy

Search terms and parameters were developed in collaboration with a Monash University librarian with expertise in systematic review methodology. The following databases were searched on 15.03.2023 to identify relevant literature: MEDLINE, PsycINFO, and SPORTDiscus. Key articles were also selected for citation searching via Scopus. In consultation with a librarian, these databases were selected due to their unique scope, relevance, broad coverage, and utility. This process ensured the identified literature aligned with the aim and research topic of our systematic review. A 01.01.2010—15.03.2023 publication period was purposefully specified to account for the significant advancements in digital fitness support and tracking tools within the past decade [ 28 ], All available records were searched using the following combination of concepts in the title or abstract of the article: 1) barriers, facilitators, or intervention, Footnote 1 2) physical activity, 3) university, and 4) students. Each search concept was created by first developing a list of search terms relevant to each concept (e.g., for the ‘physical activity’ concept search terms included ‘physical exercise’, ‘physical fitness’, ‘sports’, ‘inactive’, ‘sedentary’, etc.). To create each concept, search terms were then searched collectively using the operator ‘OR’. Each search concept was then combined into the final search by using the operator ‘AND’. Search terms related to concepts 1, 2 and 3 included indexed terms unique and relevant to each database (i.e., Medical Subject Heading Terms for MEDLINE, Index Terms for PsycINFO, and Thesaurus terms for SPORTDiscus). The search was performed according to Boolean operators (e.g., AND, OR) (see Additional file 2 for the complete search syntax for MEDLINE). Unpublished studies were not sought.

Selection criteria

Articles were included if they: (a) reported university students’ self-reported barriers and/or facilitators to physical activity or exercise Footnote 2 ; (b) were written in English; and (c) were peer-reviewed journal articles. Articles encompassed studies directly investigating barriers and/or facilitators to students’ participation in PA and physical exercise intervention studies, where the latter reported participants’ self-reported barriers and/or facilitators to intervention adherence (see Table  1 below for full criteria).

Study selection

Identified articles were uploaded to EndNote X9 software [ 30 ]. A duplication detection tool was used to detect duplicates, which were then screened for accuracy by CB prior to removal. The remaining articles were uploaded to Covidence to enable blind screening and conflict resolution. Articles were screened at the title and abstract level against the inclusion and exclusion criteria by author CB, and 25% were independently screened by BP. The full text of studies meeting the inclusion criteria was then screened against the same criteria by CB, and 25% were again independently screened by BP. Differences were resolved by an independent author (KR). Inter-rater agreement in screening between CB and BP was high (0.96 for title and abstract screening, 0.83 for full-text screening). The decision to dual-screen 25% of studies was strategically chosen to balance thoroughness with efficiency, ensuring both the validity of the screening criteria and the reliability of the primary screener’s decisions. This approach aligns with the protocols used in similar systematic reviews in the field (e.g., [ 31 , 32 ]).

Data extraction

Key article characteristics were extracted, including the author/s, year of publication, country of origin, participant characteristics (e.g., enrolment status, exercise engagement [if reported]), sample size, research design, methods, and analytical approach. Barriers and facilitators were also extracted for each article and subsequently coded according to the 14 domains of the TDF and six subcomponents of the COM-B model. Quantitative data were only extracted if ≥ 50% of students endorsed a factor as a barrier or facilitator. This cut-off criterion was applied to maintain focus on the most common variables of influence and aligns with other reviews synthesising common barriers and facilitators to behaviour change (e.g., [ 26 , 33 ]).

A coding manual was developed to guide the process of mapping barriers and facilitators to the TDF and COM-B. All articles were independently coded by at least two authors (CB and BS, BP or KR). The first version of the manual was developed a priori, based on established guides for applying the TDF and COM-B model to investigate barriers and facilitators to behaviour [ 14 , 34 ], and updated as needed via regular consultation with a co-author and TDF/COM-B designer LA to ensure the accuracy of the data extraction. Barriers and facilitators were only coded to multiple TDF domains if deemed essential to accurately contextualise the core elements of the barrier/facilitator, and when the data in individual papers was described in sufficient detail to indicate that more than one domain was relevant. For example, if ‘lack of time due to competing priorities’ was reported as a barrier to PA, this encompassed both the ‘environmental context and resources’ (i.e., time) and ‘goals’ (i.e., competing priorities) domains of the TDF. Coding conflicts were resolved via discussion with LA.

Data analysis

The following three-step method was utilised to synthesise quantitative and qualitative data:

Framework analysis [ 35 ] was conducted to deductively code barriers and facilitators onto TDF domains and COM-B subcomponents. This involved identifying barriers and facilitators in each article, extracting and labelling them, and determining their relevance against the definitions of the TDF domains and COM-B subcomponents. This process involved creating tables to assist in the systematic categorisation of barriers and facilitators into relevant TDF domains and COM-B subcomponents.

Within each TDF domain, thematic analysis [ 36 ] was conducted to group similar barriers and facilitators together and inductively generate summary theme labels.

The relative importance of each TDF domain was calculated according to frequency (number of studies), elaboration (number of themes) and the identification of mixed barriers/facilitators regarding whether a theme was a barrier or facilitator within each domain (e.g., if some participants reported that receiving encouragement from their family to exercise was a facilitator, and others reported that lack of encouragement from their family to exercise was a barrier). The rank order was determined first by frequency, then elaboration, and finally by mixed barriers/facilitators.

This methodology follows previous studies using the TDF and COM-B to characterise barriers and facilitators to behaviour change and rank their relative importance [ 22 , 23 ].

Study characteristics

Following the removal of duplicates, 6,152 articles met the search criteria and were screened based on title and abstract. A total of 5,995 articles were excluded because they did not meet the inclusion criteria (see Fig.  2 below for the PRISMA flowchart). After the title and abstract screening, 157 full-text articles were retrieved and assessed for eligibility. One additional article was identified and included following citation searching of selected key articles. Thirty-nine articles met the inclusion criteria (see Additional file 3 for a summary of these studies). Eight studies were conducted in the USA, seven in Canada, three in Germany, two each in Qatar, Spain, the United Arab Emirates, and the United Kingdom, and one each in Australia, Belgium, Columbia, Egypt, Ireland, Japan, Kuwait, Malaysia, New Zealand, Saudi Arabia, South Africa, Sri Lanka, and Uganda.

figure 2

PRISMA flowchart illustrating the article selection process

Relative importance of TDF domains and COM-B components

Twelve of the 14 TDF domains and all six subcomponents of the COM-B model were identified as relevant to university students' PA. The rank order of relative importance of TDF domains and associated COM-B subcomponents are presented in Table  2 . The three most important domains were identified in at least 54% of studies.

Barriers and facilitators to student’s physical activity

Within the TDF domains, 56 total themes were identified, including 26 mixed barriers/facilitators, 18 facilitators and 12 barriers (Table  3 ). The barriers and facilitators identified within each TDF domain are summarised below (with associated COM-B subcomponent presented in parentheses), in order of relative importance:

1. Environmental context and resources (Physical Opportunity) ( n  = 90% studies)

The most frequent barrier to PA across all TDF domains was ‘lack of time’, most often in the context of study demands. Time constraints were exacerbated by long commutes to university, family responsibilities, involvement in co-curricular activities, and employment commitments. Students’ need for ‘easily accessible exercise options, facilities and equipment’ was a recurring theme. PA was deemed inaccessible if exercise facilities and other infrastructure to support PA, such as bike paths and running trails, were situated too far from the university campus or students’ residences, or if fitness classes were scheduled at inconvenient times. ‘Financial costs’ emerged as a theme. The costs associated with accessing exercise facilities, equipment and programs consistently deterred students from engaging in PA. The desire for ‘safe and enjoyable’, ‘weather appropriate’ environments for PA were frequently reported. Participating in outdoor PA in green spaces or near water increased enjoyment, provided the environment felt safe and weather conditions were suitable for PA. Factors related to students’ home, work, and university environment impacted their participation in ‘incidental PA’. Incidental PA was influenced by whether students engaged in domestic house chores, and manual work, and actively commuted to university and between classes on-campus. Students’ ‘access to a variety of physical activities’ and ‘information provision regarding on-campus exercise options’ impacted their PA. Students most often had access to a wide variety of physical activities, however, it could be difficult to access information about what types of activities were available on-campus and how to sign up to participate. The ‘lack of personalised physical activities to cater to individual fitness needs’ was a barrier, particularly for students with low levels of PA who required beginner-oriented programs. Another barrier was the ‘lack of university policy and promotion to encourage PA’, which led students to perceive that there was no obligation to participate in PA and that the university did not value it. ‘Health-concerning behaviours associated with university’, including poor diet, increased alcohol intake and sedentary behaviour, negatively impacted students’ PA. ‘Listening to music while exercising’ was a facilitator.

2. Social influences (Social Opportunity) ( n  = 72% studies)

Within social influences, ‘exercising with others’ emerged as the most frequent theme. Doing so increased students’ accountability, enjoyment and motivation, and helped them to overcome feelings of intimidation when exercising alone. Having a lack of friends to exercise with was a particular concern for students who were new to exercise or infrequently participated in PA. Receiving ‘encouragement from others to be physically active’, such as family members, friends, peers, and fitness instructors, shaped students’ values toward PA and enhanced their motivation and self-efficacy. Students’ family members, friends and teachers discouraged PA if it was not valued, or in favour of other priorities, such as academic commitments. Another recurrent theme was ‘competition or relative comparison to others’. While most students were motivated by competition, a minority felt demotivated if they compared themselves to others with higher PA standards, especially if they failed to achieve similar PA goals. Sociocultural norms influenced barriers/facilitators to PA across different cultures, and between various groups, such as international versus domestic students, and women versus men. Students from Japan and Hawaii viewed PA as an important part of their culture, in contrast to students from the Philippines who described the opposite. Participation in PA enabled international students to integrate with domestic students and learn about the local culture, however cultural segregation was a barrier to participation in university team sports. For female students from some middle-eastern countries, including Saudi Arabia, the UAE and Qatar, cultural norms made it impermissible for women to engage in PA, particularly compared to men. Religion also differentially impacted barriers/facilitators between women and men. Muslim women reported that Islamic practices, such as needing to engage in PA separately from men, be accompanied by a male family member while going outdoors, or dress modestly, posed additional barriers to PA. However, one study reported that Islamic teachings generally encouraged PA for both women and men by emphasising the importance of maintaining good health. Other gender-specific barriers were identified. Women often felt unwelcome or intimidated by men in exercise facilities, partly due to the perception that these facilities were tailored toward “masculine” sports and/or dominated by men. ‘Being stared at while engaging in PA’ was another barrier, impacting both women and students with a disability. A less common facilitator was the influence of both positive and negative ‘exercise role models’. For example, students practiced PA because they aspired to be like someone who was physically active, or because they did not want to be like someone who was not physically active.

3. Goals (Reflective Motivation) ( n  = 54%)

‘Prioritisation of PA compared to other activities’ was the most common theme within goals. Students frequently prioritised other activities, such as study, social activities, or work, over PA. However, those who played team sports or regularly practiced PA were more inclined to prioritise it for its recognised health benefits (i.e., stress management), and its role in enhancing confidence. Additional facilitators included ‘engaging in PA to achieve an external goal’, such as improving one’s appearance, and ‘setting specific PA-related goals’ as a means to enhance accountability.

4. Intentions (Reflective Motivation) ( n  = 44%)

Within intentions, ‘motivation to engage in PA’ was the most common theme. Students most often noted a lack of self-motivation for PA. Less frequent barriers included perceiving PA as an obligatory or necessary "chore", and ‘failing to follow through on intentions to engage in PA’. Conversely, ‘self-discipline to engage in PA’ emerged as a facilitator that assisted students in maintaining a regular PA routine.

5. Reinforcement (Automatic Motivation) ( n  = 38%)

The most frequent facilitator within reinforcement was ‘experiencing the positive effects of PA’ on their health and wellbeing. These included physical health benefits (i.e., maintaining fitness), psychological benefits (i.e., stress reduction), and cognitive health benefits (i.e., enhanced academic performance). Conversely, barriers arose from ‘experiencing discomfort during or after PA’ due to pain, muscle soreness or fatigue. ‘Past and current habits and routines’ was a theme. Students were more likely to participate in PA if they had established regular exercise routines, and that forming these habits at an early age made it easier to maintain them later in life. However, maintaining a regular PA routine was difficult in the context of inflexible university schedules. Students’ ‘sense of accomplishment in relation to PA’ was a theme. Students were less likely to feel a sense of accomplishment after participating in PA if it was not physically challenging. Consistent facilitators were ‘receiving positive feedback from others’ after engaging in PA, such as compliments, and ‘receiving incentives’, such as reducing the cost of gym memberships if students participated in more PA. ‘Experiencing a sense of achievement’ after reaching a PA-related goal or winning a sports match also served as a facilitator.

6. Emotion (Automatic Motivation) ( n  = 38%)

‘Enjoyment’ was the most frequently cited emotional theme. Most students reported that PA was fun and/or associated with positive feelings, however, a minority described PA as unenjoyable, boring, and repetitive. Students’ ‘poor mental health and negative affectivity’ (such as feeling sad, stressed or self-conscious, as well as fear of injury and pain), adversely impacted their motivation to be physically active.

7. Beliefs about consequences (Reflective Motivation) ( n  = 31%)

‘Beliefs about the physical health consequences of PA’ was the most recurrent barrier/facilitator. Most students understood that PA was essential for maintaining good health and preventing illness. However, some students who rarely or never engaged in PA believed they could delay pursuing an active lifestyle until they were older without compromising their health. Participating in PA to ‘maintain or improve one’s physical appearance’ acted as a facilitator. This motivation was most often cited in contexts such as increasing or decreasing weight, changing body shape or enhancing muscle tone. Beliefs about the positive environmental, occupational and psychological impacts of PA also served as facilitators. Students were motivated to participate in PA due to the environmental benefits of using active transport. They also acknowledged the importance of being physically fit for work and believed that being active was beneficial for mental health. ‘Receiving advice to participate in PA from a credible source’, such as a health professional, further facilitated students’ motivation to be active.

8. Knowledge (Psychological Capability) ( n  = 28%)

'Knowledge about the benefits of PA’, encompassing an understanding of the various types of benefits (i.e., physical, mental, or cognitive) and the biological mechanisms by which PA brings about these changes was identified as the most common knowledge theme. Being aware of these benefits positively influenced students’ motivation to be physically active. Conversely, students’ lack of knowledge about the gym environment and the programs available were barriers to PA. Regarding the gym environment, students’ ‘lack of knowledge about how to navigate through the gym, what exercises to do, and how to use exercise equipment’ amplified feelings of intimidation. Likewise, ‘lack of knowledge about the types of exercise programs and activities that were available on-campus, and how to sign up to participate’ were all barriers. A unique theme emerged concerning ‘knowledge about how to adapt physical activities for students with a disability’. Students with a disability described how fitness instructors often had a limited understanding of how to modify activities to enable them to participate. However, students with a disability were able to overcome this barrier if they possessed their own knowledge about how to tailor physical activities to meet their specific needs.

9. Physical skills (Physical Capability) ( n  = 21%)

The most prevalent theme within physical skills was ‘having the physical skills and fitness to participate in PA’. A lack of physical skills was most frequently a hindrance to PA. Additional obstacles to PA included being physically inhibited due to a ‘lack of energy’ or ‘physical injury’.

10. Beliefs about capabilities (Reflective Motivation) ( n  = 18%)

Within beliefs about capabilities, ‘self-efficacy to participate in PA’ was the most recurrent theme. Students who doubted their success in becoming physically active or who lacked confidence in their ability to initiate PA or participate in sport were less motivated to take part. A less frequent facilitator was students’ ‘self-affirmation to participate in PA’, often referring to positive cognitions about one’s own physical abilities.

11. Cognitive and interpersonal skills (Psychological Capability) ( n  = 15%)

‘Time-management’ was the only theme identified within cognitive and interpersonal skills. Students who struggled to manage their time effectively found it difficult to incorporate regular PA into their daily routine.

12. Social/professional role and identity (Reflective Motivation) ( n  = 8%)

The most frequent theme within social/professional role and identity was ‘perceiving PA as a part of one’s self-identity’. Students who engaged regularly in PA often considered it integral to their identity. Conversely, students who perceived they did not align with the aesthetic and superficial stereotypes commonly associated with the fitness industry felt less motivated to be active. A specific facilitator emerged among physiotherapy students, who were motivated to be active due to the emphasis on PA within their profession.

13. Behavioural regulation (Psychological Capability) ( n  = 3%)

Within the domain of behavioural regulation, two facilitators were equally prevalent: ‘self-monitoring of PA’ and ‘feedback on progress towards a PA-related goal’. By keeping track of their step count and receiving feedback on walking goals, students were motivated to exceed the average number of daily steps or achieve their personal PA targets.

14. Memory, attention, and decision process (Psychological Capability); Optimism (Reflective Motivation) ( n  = 0%)

No barriers or facilitators relating to the TDF domains of memory, attention and decision process, or optimism were identified.

This systematic review used the TDF and COM-B model to identify barriers and facilitators to PA among university students and rank the relative importance of each TDF domain. It is the first review to apply these frameworks in the context of increasing university students’ participation in PA. Twelve TDF domains across all six sub-components of the COM-B model were identified. The three most important TDF domains were ‘environmental context and resources’, ‘social influences’, and ‘goals’. The most common barriers and facilitators were ‘lack of time’, ‘easily accessible exercise options, facilities and equipment’, ‘exercising with others’, and ‘prioritisation of PA compared to other activities’.

The most common barrier to PA was perceived lack of time. This is consistent with previous findings among university students [ 13 , 74 ] and across other populations [ 24 ], For students, lack of time was frequently attributed to a combination of competing priorities and underdeveloped time management skills. Students predominantly prioritised study over PA, as performing well at university is a valued goal and there is a common perception that spending time exercising (at the expense of study) will impede their academic success [ 53 , 58 ]. Evidence from cognitive neuroscience research, however, suggests that this is a mistaken belief. In addition to its broad physical and mental health benefits, a growing body of evidence demonstrates regular PA can change the structure and function of the brain.

These changes can, in turn, enhance numerous aspects of cognition, including memory, attention, and processing speed [ 4 , 75 , 76 , 77 ], and buffer the negative impact of stress on cognition [ 78 ], all of which are important for academic success. However, students are typically unaware of the brain and cognitive health benefits of PA and its potential to improve academic performance, particularly compared to the physical health benefits [ 37 , 40 , 64 ]. Interventions that position participating in PA as a conduit for helping, rather than hindering, academic goals could increase the relative importance of PA to students and therefore increase their motivation to regularly engage in it. The impact that interventions of this nature have on students’ PA is yet to be empirically assessed.

Ineffective time management also contributed to students’ perceived lack of time for PA. Students reported tendencies to procrastinate in the face of overwhelming academic workloads, which left limited time for PA [ 53 ]. Additionally, students lacked an understanding of how to organise time for PA around academic timetables, social and family responsibilities, co-curricular activities, and employment commitments [ 9 , 44 , 53 , 59 ]. To address these challenges, efforts to develop students’ time management skills will be useful for enabling students to regularly participate in PA. Goal-setting and action planning are two specific examples of such skills that can be integrated into interventions to help students initiate and maintain a PA routine [ 79 ]. For example, goal-setting could involve setting a daily PA goal, and action planning could involve planning to engage in a particular PA at a particular time on certain days.

While the most common determinants of university students’ PA levels were not influenced by specific demographic characteristics, several barriers disproportionately impacted women and students with a disability. These findings are in keeping with evidence that PA is lower among these equity-deserving groups compared with the general population [ 68 , 80 ]. For women, particularly those from Middle Eastern cultures, restrictions were often tied to religious practices and sociocultural norms that limited their opportunities to engage in PA [ 45 , 48 , 66 ]. Additionally, a substantial number of women felt intimidated or self-conscious when exercising in front of others, especially men [ 48 , 49 ]. They also felt that exercise facilities were more often tailored towards the needs of men, leading to a perception that they were unwelcome in exercise communities [ 45 , 48 ]. Consequently, women expressed a desire for women-only spaces to exercise to help them overcome these gender-specific barriers to PA [ 47 , 48 , 66 ]. Furthermore, students with a disability faced physical accessibility barriers and perceived stigmatisation that deterred them from PA [ 50 , 52 ]. The lack of accessible exercise facilities and suitable equipment, programs, and education regarding how to adapt physical activities to accommodate their needs limited their opportunity and ability to participate [ 52 ]. Moreover, students with a disability felt stigmatised by others for not fitting into public perceptions of ‘normality’ or the aesthetic values and beauty standards often portrayed by the fitness industry [ 50 ]. These barriers for both equity-deserving groups of students are deeply rooted in historical stereotypes that have traditionally excluded women and people with a disability from engaging in various types of PA [ 81 , 82 ]. Despite growing awareness of these issues, PA inequalities persist due to narrow sociocultural norms, and a lack of diverse representation and inclusion in the fitness industry and associated marketing campaigns [ 83 , 84 ]. A concerted effort to address PA inequalities across the university sector and fitness industry more broadly is needed. One approach for achieving this is to develop interventions that are tailored to the unique needs of equity-deserving groups, emphasise inclusivity, diversity, and empowerment, and feature women and people with a disability being active.

The “This Girl Can” [ 85 ] and “Everyone Can” [ 86 ] multimedia campaigns are two examples of health behaviour interventions that were co-developed with key stakeholders (i.e., women and people with a disability, respectively) to tackle PA inequalities. The “This Girl Can” campaign has reached over 3 million women and girls, projecting inclusive and positive messages that aim to empower them to be physically active. Following the widespread reach of the “This Girl Can” campaign, the “Everybody Can” campaign was launched to support the inclusion of people with a disability in the PA sector. Although not tailored for university students, these campaigns provide a useful example for developing interventions that are specifically designed to address key barriers preventing women and people with a disability from participating in PA.

Across the tertiary education sector globally, efforts to elevate opportunities and motivation to include PA as a core part of the student experience will be beneficial for promoting students’ PA at scale. Two intervention approaches that can be implemented to facilitate such an endeavour are environmental restructuring and enablement [ 17 ]. These intervention approaches should involve the provision of accessible low-cost exercise options, facilities, and programs, integrating PA into the university curriculum, and mobilising student and staff leadership to encourage students’ participation in PA [ 9 ]. Although there is evidence that these approaches can be effective in promoting sustained PA throughout students’ university years and beyond [ 87 ], implementation measures such as these are complex. Implementation requires aligning student activity levels with broader university goals and is further complicated by having to compete with other funding priorities and resource allocations. Notably, due to the negative impact of the COVID-19 pandemic on university students’ physical and mental health [ 88 , 89 ], the post-pandemic era has seen many universities prioritise enhancing student health and wellbeing alongside more traditional strategic goals like academic excellence and workforce readiness. Despite the potential for PA to be used as a vehicle for supporting these strategic goals there is an absence of data on the extent to which this is occurring in the university sector. The limited evidence in this area suggests that some universities have made efforts to support students’ mental health by referring students who access on-campus counselling services to PA programs [ 90 ]. However, the uptake and efficacy of such initiatives is rarely assessed, and even less is known about whether PA is being used to support other strategic goals, such as academic success. Therefore, while the potential is there for the university sector to use PA to support students’ mental health and academic performance, to be successful this needs to become a strategic university priority. Given that these strategic priorities are set at the senior leadership level, engaging senior university staff in intervention design and promotion efforts is important to enhance the value of PA in the tertiary education sector.

Implications for intervention development

The current findings provide a high-level synthesis of the most common barriers and facilitators to university students’ physical activity. These findings can be leveraged with behavioural intervention development tools and frameworks (e.g., the BCW [ 17 ], Obesity-Related Behavioural Intervention Trials model [ 91 ], Intervention Mapping [ 92 ], and the Medical Research Council guidelines for developing complex interventions [ 93 , 94 ]) to develop evidence-based interventions and policies to promote PA. Given that the TDF and COM-B model are directly linked to the BCW framework, applying this process may be particularly useful to translate the current findings into an intervention.

Additionally, current findings can be triangulated with data directly collected from key stakeholders to assist in the development of context-specific interventions. Best practice principles for developing behavioural interventions recommend this approach to ensure a deep understanding of the barriers and facilitators that need to be targeted to increase the likelihood of behaviour change [ 17 ]. Consulting stakeholders directly (i.e., university students and staff) to understand their perspectives on the barriers and facilitators to students’ PA also enables an intervention to be appropriately tailored to the target population’s needs and implementation setting. Studies continue to demonstrate the effectiveness of this approach, especially when framed within the context of frameworks directly linked to intervention development frameworks, such as the TDF [ 95 ].

Strengths and limitations

The findings of this review should be considered with respect to its methodological strengths and limitations. The credibility and reliability of the research findings are supported by a systematic approach to screening and analysing the empirical data, along with the use of gold-standard behavioural science frameworks to classify barriers and facilitators to PA. The inclusion of qualitative, quantitative, and mixed-methods studies of both barriers and facilitators to students’ PA allowed for a comprehensive understanding of the factors that influence students’ PA that have not previously been captured.

While the present review elucidates students’ own perspectives of the factors that influence their activity levels, other stakeholders such as university staff, will also influence the adoption, operationalisation, and scale of PA interventions in a university setting. It will be important for future research to explore factors that influence university decision-makers in these roles to inform large-scale strategies for promoting students' PA.

Additionally, only one study included in the review used the TDF to explore barriers and facilitators to PA [ 47 ]. Therefore, it is possible that certain TDF domains may not have been identified because students were not asked relevant questions to assess the influence of those domains on their PA. For instance, domains such as ‘memory, attention, and decision process’, and ‘optimism’ are likely to play a role in understanding the barriers and facilitators to PA despite not being identified in this review.

Moreover, quantitative data were only extracted if ≥ 50% of students endorsed the factor as a barrier or facilitator to PA. This threshold was purposefully applied to maintain a focus on the TDF domains most universally relevant to the broad student population in the context of understanding their barriers and facilitators to PA. It is possible that less frequently reported barriers and facilitators, which may not be as prominently featured in the results, could be relevant to specific groups of students, such as those identified as equity-deserving.

Lastly, a quality appraisal of the included studies was not undertaken. This decision was informed by the aim of the review, which was to describe and synthesise the literature to subsequently map data to the TDF and COM-B rather than assess the effectiveness of interventions or determine the strength of evidence. However, this decision, combined with dual screening 25% of the studies and excluding unpublished studies and grey literature, may introduce sources of error and bias, which should be considered when interpreting the results presented.

PA is an effective, scalable, and empowering means of enhancing physical, mental, and cognitive health. This approach could help students reach their academic potential and cope with the many stressors that accompany student life, in addition to setting a strong foundation for healthy exercise habits for a lifetime. As such, understanding the barriers and facilitators to an active student lifestyle is beneficial. This systematic review applied the TDF and COM-B model to identify and map students’ barriers and facilitators to PA and, in doing so, provides a pragmatic, theory-informed, and evidence-based foundation for designing future context-specific PA interventions. The findings from this review highlight the importance of developing PA interventions that focus on the TDF domains ‘environmental context and resources’, ‘social influences’, and ‘goals’, for which intervention approaches could involve environmental restructuring, education, and enablement. If successful, such strategies could make a significant contribution to improving the overall health and academic performance of university students.

Availability of data and materials

The review protocol is available on PROSPERO. The datasets used and/or analysed during the current study and materials used are available from the corresponding author on reasonable request.

The term ‘intervention’ was included to identify student barriers and facilitators to engaging in implemented physical activity interventions.

Physical exercise is defined as “a subset of physical activity that is planned, structured, and repetitive”, and purposefully focused on the improvement or maintenance of physical fitness, whereas physical activity is defined as “any bodily movement produced by skeletal muscles that results in energy expenditure” [ 96 ].

Abbreviations

Behaviour Change Wheel

Capability, Opportunity, Model-Behaviour

  • Physical activity

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

International Prospective Register of Systematic Reviews

Theoretical Domains Framework

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Acknowledgements

The authors extend their gratitude to the funder, the nib foundation, for its financial support, which was instrumental in facilitating this research. We are also indebted to the Wilson Foundation and the David Winston Turner Endowment Fund for their generous philanthropic contributions, which have supported the BrainPark research team and facility where this research was conducted. Special thanks are owed to the library staff at Monash University for their expertise in conducting systematic reviews, which helped inform the selection of databases and the development of the search strategy.

This research was supported by nib foundation. The nib foundation had no role in the design of the study and collection, analysis, and interpretation of data, and in writing the manuscript. The views expressed are those of the authors and not necessarily those of the nib foundation.

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Catherine E. B. Brown, Karyn Richardson, Bengianni Halil-Pizzirani & Rebecca A. Segrave

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CB, KR, BP, LA and RS developed the review protocol. CB and BP conducted the search and screened articles, and KR resolved conflicts. CB, KR, BP, LA and RS extracted the barriers and facilitators, mapped barriers and facilitators to the TDF and COM-B model, and interpreted the results. CB drafted the paper. All authors read, revised, and approved the submitted version.

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Brown, C.E.B., Richardson, K., Halil-Pizzirani, B. et al. Key influences on university students’ physical activity: a systematic review using the Theoretical Domains Framework and the COM-B model of human behaviour. BMC Public Health 24 , 418 (2024). https://doi.org/10.1186/s12889-023-17621-4

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Medical, Health and Wellness Tourism Research—A Review of the Literature (1970–2020) and Research Agenda

1 Institute for Big Data Research in Tourism, School of Tourism Sciences, Beijing International Studies University, Chaoyang District, Beijing 100024, China; nc.ude.usib@anilgnohz (L.Z.); moc.361@5220niloabgned (B.D.); moc.361@gnay__uyil (L.Y.)

Baolin Deng

Alastair m. morrison.

2 Greenwich Business School, Old Royal Naval College, University of Greenwich, London SE10 9SL, UK; [email protected]

J. Andres Coca-Stefaniak

Associated data.

Data are reported in the article.

Medical, health and wellness tourism and travel represent a dynamic and rapidly growing multi-disciplinary economic activity and field of knowledge. This research responds to earlier calls to integrate research on travel medicine and tourism. It critically reviews the literature published on these topics over a 50-year period (1970 to 2020) using CiteSpace software. Some 802 articles were gathered and analyzed from major databases including the Web of Science and Scopus. Markets (demand and behavior), destinations (development and promotion), and development environments (policies and impacts) emerged as the main three research themes in medical-health-wellness tourism. Medical-health-wellness tourism will integrate with other care sectors and become more embedded in policy-making related to sustainable development, especially with regards to quality of life initiatives. A future research agenda for medical-health-tourism is discussed.

1. Introduction

In 1841, Thomas Cook organized a tour of 570 people to travel from Leicester to Loughborough’s hot springs [ 1 ]. This was the first historically documented tour arranged by a travel agent. However, far earlier, people in Ancient Greece used to travel considerable distances for medical treatment [ 2 ]. Thus, the pursuit of health and medical care has been an essential reason for travel for centuries.

Today, people continue to travel in the pursuit of relaxation, for health reasons, as well as fitness and well-being [ 3 ]. As a response to this growing demand, countries, medical providers, and hospitality and tourism organizations are adapting to offer a broader set of medical, health, and wellness tourism experiences.

The concept of medical-health-wellness tourism has emerged relatively recently as a scholarly field of enquiry in tourism [ 4 , 5 , 6 ]. Although it has been pointed out that travel medicine has existed for 25 years [ 7 ], much of the research related to this has traditionally focused on medical aspects with inadequate consideration given to travel or tourism. Medical-health-wellness tourism can be classified into two primary categories according to a tourist’s choice - obligatory or elective. Obligatory travel occurs when required treatments are unavailable or illegal in the place of origin of the traveler and, as a result of this, it becomes necessary to travel elsewhere to access these services. Elective travel is usually scheduled when the time and costs are most suitable, and the treatments may even be available in the travelers’ home regions [ 8 ]. Other studies have classified these forms of travel and tourism into specific types based on the purpose of the treatment, such as dental tourism [ 9 ], stem cell tourism [ 10 ], spa tourism [ 11 ], springs tourism [ 12 ], IVF treatment [ 13 ], hip and knee replacements, ophthalmologic procedures, cosmetic surgery [ 5 ], cardiac care, and organ transplants [ 14 ].

A consensus is yet to be established on the definitions and contents of medical-health-wellness tourism, and how they interact, including their potential overlaps. Medical travel and tourism, health tourism, wellness tourism, and other similar terms (e.g., birth tourism, cosmetic surgery tourism, dental tourism) tend to be investigated separately in tourism research [ 15 , 16 , 17 , 18 , 19 , 20 ]. Notwithstanding the apparently disconnected nature of published research in this field, medical-health-wellness tourism has become much more popular for a variety of economic, cultural, lifestyle and leisure reasons [ 11 , 21 , 22 ]. Given their rapid development, it seems appropriate to conduct a comprehensive review of the definitions, history, typologies, driving factors, and future directions for these forms of tourism.

This study firstly reviews existing scholarly research through a meta-analysis of medical-health-wellness publications in the context of tourism ( Section 2 ). Then, the method used to analyze the data collected from ISI Web of Science is outlined in Section 3 , followed by a discussion of the research findings ( Section 4 ). Finally, in Section 5 , the conclusions, future research directions, and limitations of the study are presented.

2. Scholarly Reviews and Meta-Analyses of Medical, Health and Wellness Tourism

Previous reviews of the literature and meta-analyses have contributed to clarifying the overall understanding of medical-health-wellness tourism. Existing literature reviews tend to be very broad, spanning health-oriented tourism, medical tourism, sport and fitness tourism, adventure tourism, well-being (Yang sheng in Chinese) tourism, cosmetic surgery tourism, spa tourism, and more.

Medical tourism is an expanding global phenomenon [ 15 , 23 , 24 ]. Driven by high healthcare costs, long patient waiting lists, or a lack of access to new therapies in some countries, many medical tourists (mainly from the United States, Canada, and Western Europe) often seek access to care in Asia, Central and Southern Europe, and Latin America [ 25 , 26 , 27 ]. There are potential biosecurity and nosocomial risks associated with international medical tourism [ 28 ]. One research study collected 133 electronic copies of Australian television programs (66 items) and newspapers (65) about medical care overseas from 2005 to 2011 [ 29 ]. By analyzing these stories, the researchers discovered that Australian media coverage of medical tourism was focused geographically mainly on Asia, featuring cosmetic surgery procedures and therapies generally not available in Australia. However, people tend to engage with medical tourism for a broad range of reasons. In some cases, it is better service quality or lower treatment costs that prevail. In other cases, treatments may not be available locally, or there are long patient waiting lists for non-emergency medical care. Some 100 selected articles were reviewed and categorized into different types of medical tourism depending on the medical treatments they involved, such as dentistry, cosmetic surgery, or fertility work [ 25 ]. An analysis was done on 252 articles on medical tourism posted on the websites of the Korean Tourism Organization and the Korean International Medical Association [ 30 ]. This work enhanced the understanding of medical tourism in Korea as well as identifying the key developmental characteristics. Another research study detailed patient experiences in medical travel, including decision making, motivations, risks, and first-hand accounts [ 31 ]. A literature review was conducted on international travel for cosmetic surgery tourism [ 5 ] and it concluded that the medical travel literature suffered from a lack of focus on the non-surgery-related morbidity of these tourists.

Another set of authors defined health tourism as a branch of tourism in general in which people aim to receive specific treatments or seek an enhancement to their mental, physical, or spiritual well-being [ 32 ]. This systematic literature review assessed the value of destinations’ natural resources and related activities for health tourism. It was argued that most of the research on health tourism has focused on travel from developed to developing countries, and that there is a need to study travel between developed nations [ 33 ].

Wellness tourism is a key area of relevant research as well [ 34 ]. One research study reviewed trends in wellness tourism research and concluded that tourism marketing had so far failed to tap into the deeper meaning of wellness as a concept [ 35 ]. The emergence of health and wellness tourism was explored with their associated social, political, and economic influences [ 13 ]. A review was conducted of the development of wellness tourism using the concept of holistic wellness tourism where it was found that the positive impacts of this type of tourism on social and economic well-being were key to its rising levels of popularity [ 36 ].

All in all, although earlier literature reviews provide invaluable insights into medical-health-wellness tourism, there is a lack of studies that approach this concept in a holistic way. This research seeks to redress this balance by delivering a holistic review of the literature with the following objectives in mind: (1) investigating international journal articles across the typologies of tourism outlined above; (2) identifying influential scholars that have significantly contributed to this field; and (3) summarizing key trends in markets, industry development and promotion, as well as policy-making and impacts. In order to achieve this, a systematic review was conducted to analyze research articles in medical-health-wellness tourism published over a 50-year period from 1970 to 2020.

3.1. Data Collection

A two-step approach was adopted for the development of a database of publications for analysis with CiteSpace. The first step involved a search for relevant, high-quality refereed articles in medical-health-wellness tourism. Several academic journal databases, within tourism and hospitality but also including other disciplines too, were searched for relevant articles in medical-health-wellness tourism using a set of selected keywords. The ISI Web of Science and Scopus were chosen for this purpose as a result of their international recognition and comprehensiveness. Articles included in the list of references of selected articles were also considered valid as part of this search, in line with methodological suggestions for systematic literature searches [ 37 ]. Cited articles were also collected from prominent journals, including the Southern Medical Journal, Journal of Travel Medicine, BMC Public Health, Annals of Tourism Research, Tourism Management, Journal of Travel Research, and Journal of Vacation Marketing. Non-tourism related journals were selected as well including Amfiteatru Economic, Asia Pacific Viewpoint, Public Personal Management, and Revista de Historia Industrial. Adding these references not only delivered a higher number of relevant articles to the database, but it also increased its representativeness.

The second step involved using appropriate, valid and representative search keywords. A total of 986 articles were gathered using the following keywords: medical tourism, health tourism, wellness tourism, and spa tourism. After careful sorting of these publications, using their abstracts and keywords, the number of articles in the database was narrowed down to 802. Of these, 615 were obtained using the keywords medical tourism or wellness tourism, 157 were located by searching for health tourism, and 30 were discovered using spa tourism as the search term. Using the above keywords and restricting the search to 50 years (1970–2020), the first article was found to be published in 1974. As a result, the ensuing analysis of the literature comprises the period from 1974 to 2020.

3.2. Data Analysis

The research tool used for this study was CiteSpace, which is a bibliometric analysis software developed by Professor Chaomei Chen of Drexel University based on the Java framework [ 38 ]. This software assists researchers in the analysis of research trends in a specific field of knowledge and presents scientific knowledge structures through visualization. It has been applied to numerous research fields by scholars from many countries. The data processing for this research used the software V.5.7.R2 (64-bit) version.

The data were classified and analyzed to achieve three specific goals. The first and primary goal of this review work was to analyze the content of the chosen articles, including year of publication, authors, journal impact factors, and the institutional affiliations of scholars in this field. The data were then sorted into categories. The order of authorship was not recorded. For multiple-authored articles, each author was given the same level of credit as sole authors. Second, one of the aims of this research was to discover associations in authorships, regions, and affiliations using statistical analysis. Third, the 802 articles were classified into dominant thematic categories applying the approach proposed by Miles and Huberman [ 39 ]. Three flows of analytical activities were targeted here: data reduction, data display, and verification of data. In the data reduction activity, the word count technique was adopted. Through content analysis, each article’s title and full-text body were recorded for word counting. The most frequently appearing words were extracted to represent the main topics of the collected articles. The dominant thematic categories to be explored further based on the content analysis and word count were: (1) tourism market: tourist demand and behavior; (2) tourism destinations: development and promotion; and (3) tourism development contexts: policies and impacts.

Finally, in order to refine the set of topic sub-categories, abstracts, first paragraphs, and conclusions were read to make the most appropriate assignments. This approach contributed to the more advanced stages of development of the classification of sub-categories and, consequently, the verification of findings.

This section presents the results of the data analysis carried out in this study and provides further insights on the methodology adopted.

4.1. Overview of Articles Published

The 802 articles selected were all published in English and in international peer-reviewed academic journals. Figure 1 displays the timeline distribution of the research on medical-health-wellness tourism and shows a steady growth in publications in this field between 1974 and 2020. This growth in scholarly activity is particularly significant from 2010 onwards. In fact, 74.9% of the articles were published between 2013 and 2020.

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Number of articles by publication year.

4.2. Source Journals

Initially, the first stage of this literature search involved identifying academic journals publishing research articles on medical-health-wellness tourism. It was found that 38 articles had been published on this topic in Tourism Management, and 24 articles in Social Science & Medicine. Table 1 shows the top ten tourism journals for publications in this field, with Tourism Management in first place.

Tourism journals publishing articles on medical-health-wellness tourism.

Non-tourism journals in fields such as business, economics, and health, also contributed a significant number of publications in this field, as shown in Table 2 .

Non-tourism journals publishing articles on medical-health-wellness tourism.

4.3. Author Productivity and Authorship Analysis

The second aim was to identify the most prolific scholars in medical-health-wellness tourism research. This was achieved using co-occurrence network analysis of the authors of relevant research articles ( Figure 2 ). Each node in the co-occurrence map shown in Figure 2 represents a given scholar. The larger the node, the more articles the authors published on the topic, with the connections between nodes representing cooperation between authors.

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Author article productivity.

Among the 2381 authors identified, 1820 (76.4%) contributed to only one article, whereas the remaining 561 (23.6%) authored two or more articles. The three most prolific authors were Jeremy Snyder, Valorie Crooks, and Rory Johnston.

4.4. Author Regions and Affiliations

Another objective was to illustrate the relationships and networks of authors publishing research on medical-health-wellness tourism. An analysis of countries this research originated from was carried out using the CiteSpace software. Figure 3 shows that scholars publishing in this field were distributed across 61 countries. The largest group of authors originated from the USA ( n =197). The second and third largest groups corresponded to Canada ( n = 88) and the UK ( n = 84), respectively, followed by Australia ( n = 70) and South Korea ( n = 65). As shown in Figure 3 , authors from the USA and Canada have made the most significant contributions to medical-health-wellness tourism based on the number of journal articles published.

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Country of origin of authors in medical-health-wellness tourism.

As shown in Figure 4 , a significant number of scholars publishing in this field ( n = 47) were affiliated to Simon Fraser University in Canada. This university was followed by Sejong University in South Korea ( n = 13), and the London School of Hygiene & Tropical Medicine ( n = 13) in the UK. The top universities in terms of author frequency were based in Canada, USA, Australia, UK, South Korea, and Hong Kong.

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Institutions of authors.

4.5. Thematic Analysis of Research

The fourth research objective was to elicit the prevailing research themes using the 802 articles gathered. First, an analysis of keyword frequency was performed to identify the main research interests. High frequency keywords reflect the research ‘hotspots’ in the field. Using CiteSpace’s keyword visualization analysis function, the keyword co-occurrence knowledge map of medical-health-wellness tourism research was drawn to grasp the research ‘hotspots’ ( Figure 5 ).

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Frequencies of research keywords.

Then, content analysis performed on the articles gathered for this study identified three main themes, namely: markets (tourist demand and behavior), destinations (development and promotion), and development environments (policies and impacts). An uneven distribution of research themes is highlighted in Figure 6 and Figure 7 .

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Timeline of research keyword appearance.

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Themes of research articles.

4.6. Markets: Demand and Behavior

Previous studies have shown that the growth of medical-health-wellness tourism in developing countries is largely linked to lower costs, shorter patient waiting lists, and better quality of care [ 40 ]. Similarly, it is suggested that the inequalities and failures in domestic health care systems often lead to people seeking treatment to travel abroad to obtain it [ 41 ]. In general terms, higher costs, long patient waiting lists, the relative affordability of international air travel, favorable exchange rates, and the availability of well-qualified doctors and medical staff in developing countries, all contribute to this situation [ 42 ].

As the demand for these forms of tourism has risen over time, processes and factors influencing decision-making have attracted growing levels of scholarly enquiry. For example, a political responsibility model was used to develop a decision-making process for individual medical tourists [ 43 ]. A sequential decision-making process has been proposed, including considerations of the required treatments, location of treatment, and quality and safety issues attendant to seeking care [ 44 ]. Accordingly, it has been found that health information and the current regulatory environment tend to affect the availability of medical care.

Multiple factors may simultaneously influence decisions related to the destination for care, including culture [ 45 ], social norms [ 46 ], religious factors [ 47 ], and the institutional environment [ 48 ]. It is suggested that socioeconomic conditions shape medical travelers’ decision-making and spending behavior relative to treatment, accommodation, and transport choices as well as the length of stay [ 49 ]. Perceived value is a key predictor of tourist intentions. More specifically, perceived medical quality, service quality, and enjoyment significantly influence the intention to travel abroad for medical-health-wellness purposes [ 50 ]. Further, perceived quality, satisfaction, and trust in the staff and clinics have significant associations affecting intentions to revisit clinics and the destination country [ 51 ]. An empirical study was conducted and found that physical convenience in willingness to stay and time and effort savings in perceived price were key factors affecting the decision-making related to medical hotels [ 52 ]. In addition, the level of perceived advantages, price perceptions, and willingness to stay were found to differ significantly between first-time patients and those with two or more previous visits. In addition, it was found that community communication was a major factor influencing decision-making. For instance, it is argued that virtual community membership has a strong influence on tourist behaviors and the way information is transmitted [ 53 ].

Compared to other tourists, the mental activity and behavior of medical-health-wellness travelers are quite different. Medical tourists are less likely to question their need for surgery and tend to be much readier to accept it [ 54 ]. The emotion and anxiety conditions of medical tourists differ from others’ experiences of travel and tourism, as well as their giving and receiving of transnational health care [ 55 ]. It has been found that language barriers and parenting responsibilities can be significant challenges, while hospital staff and their own families are often major sources of support for medical tourists [ 56 ]. Furthermore, there are significant differences among visitors from different countries in terms of choices, discomfort, preferred product items, and attitudes towards medical tourism [ 57 , 58 ].

4.7. Destinations: Development and Promotion

In response to the demands of medical-health-wellness tourism, destination development and promotion are attracting growing levels of scholarly interest. Scholars from different countries have discussed the market status of Turkey [ 12 , 59 ], the Caribbean [ 60 ] and Barbados [ 61 ], India [ 62 , 63 ], Canada [ 64 ], and Albania [ 65 ]. Table 3 outlines the most frequently researched country destinations in this respect.

Medical-health-wellness destination frequency in keywords.

The advantages and disadvantages of Turkey were examined and indicated needs for improvements [ 59 ]. In another research study, three years (2005, 2007, and 2011) of actual and projected operational cost data were evaluated for three countries: USA, India, and Thailand [ 66 ]. This study discussed some of the inefficiencies in the U.S. healthcare system, drew attention to informing uninsured or underinsured medical tourists of the benefits and risks, and determined the managerial and cost implications of various surgical procedures in the global healthcare system.

As regards medical-health-wellness tourism destination development, scholars have explored research from various perspectives. Conceptual frameworks have been developed to include tourism destinations and services in the context of medical and health tourism [ 59 , 67 ]. Advice has been provided from the perspective of public and private hospital doctors [ 68 ]. The principles of designing hospital hotels have been proposed, including proper planning, low prices of tourism services, medical education, creating websites on medical tourism, and health tourism policy councils [ 69 ]. Above all, scholars have posited that meeting or exceeding tourist expectations and requirements should remain the top priorities as regards the effective development of medical tourism destinations [ 69 , 70 ].

Once a medical-health-wellness tourism destination is developed successfully, marketing and promotion are essential to attract tourists. As part of this process, informing potential patients about procedural options, treatment facilities, tourism opportunities, and travel arrangements are the keys to success [ 71 ]. Most tourists rely on the Internet to gather information about destinations, often using mobile devices or personal computers [ 72 ], with websites and social media playing a key role in this respect, and specifically with regards to information about destinations’ medical facilities, staff expertise, services, treatments, equipment, and successful cases [ 73 ]. For example, apps for medical travel are available to attract tourists and promote medical tourism in Taiwan [ 74 ].

Numerous businesses promote medical-health-wellness travel, including medical travel companies, health insurance companies, travel agencies, medical clinics, and hospitals [ 75 ]. Among them, medical travel facilitators play a significant role as engagement moderators between prospective patients in one country and medical facilities elsewhere around the world [ 76 ]. The services offered on medical tourism facilitator websites vary considerably from one country to another [ 77 ]. Although medical travel facilitators operate on a variety of different scales and market their services differently, they all emphasize the consumer experience through advertising quality assurance and logistical support [ 78 ].

Scholarly research has also considered the factors that need to be taken into consideration in medical-health-wellness tourism promotion. This research has suggested that destinations should identify the specifics in their health tourism resources, attractions, and products, seek collaboration with others, and build a common regional brand [ 79 ]. Regional differences should be considered in the process of marketing as medical-health-wellness tourism is a global industry [ 77 ]. International advertisers need to understand the important, contemporary, and cultural characteristics of target customers before promotion [ 80 ]. Similarly, destinations need to portray safe and advanced treatment facilities to dispel potential patient worries and suspicions. Messages related solely to low cost may detract from and even undermine messages about quality [ 71 ]. However, while benefits are highly emphasized online, websites may fail to report any procedural, postoperative, or legal concerns and risks associated with medical tourism [ 81 ].

4.8. Development Environments: Policies and Impacts

The rise of medical-health-wellness tourism emphasizes the privatization of healthcare, an increasing dependence on technology, and the accelerating globalization of healthcare and tourism [ 82 ]. There are challenges and opportunities in the development of these tourism forms. For instance, it has been suggested that medical tourism distorts national health care systems, and raises critical national economic, ethical, and social questions [ 83 ]. Along with the development of medical-health-wellness tourism, social-cultural contradictions [ 84 ] and economic inequities are widening in terms of access, cost, and quality of healthcare [ 85 ]. It is argued that this tourism leads destinations to emphasize tertiary care for foreigners at the expense of basic healthcare for their citizens [ 86 ]. Moreover, in some instances, this phenomenon can exacerbate the medical brain drain from the public sector to the private sector [ 43 , 87 , 88 ], leading to rising private health care and health insurance costs [ 88 ].

While medical-health-wellness tourism is a potential source of revenue, it also brings a certain level of risk to destinations and tourists [ 89 ]. The spread of this type of tourism has been posited as a contributing factor to the spread of infectious diseases and public health crises [ 90 , 91 ]. Medical tourists are at risk of hospital-associated and procedure-related infections as well as diseases endemic to the countries where the service is provided [ 92 ]. Similarly, the safety of some treatments offered has also been the subject of growing levels of scrutiny. Contemporary scholarship examining clinical outcomes in medical travel for cosmetic surgery has identified cases in which patients traveled abroad for medical procedures and subsequently returned home with infections and other surgical complications [ 93 ]. Stem cell tourism has been criticized on the grounds of consumer fraud, blatant lack of scientific justification, and patient safety [ 94 , 95 ]. During the process of medical tourism, inadequate communication, and information asymmetry in cross-cultural communication may bring medical risks [ 96 ].

Medical-health-wellness tourism has emerged as a global healthcare phenomenon. Policy guidance is vital for the development of this sector in the future [ 97 ]. There are policy implications for the planning and development of medical-health-wellness tourism destinations [ 98 ]. Generally, it has been found that the medical-health-wellness tourism sector tends to perform better in countries with a clear policy framework for this activity [ 99 ]. Similarly, scholars have argued the need for a clearer policy framework regulating tourism agencies and the information and services they provide [ 100 ]. The upsurge of these tourism forms presents new opportunities and challenges for policy makers in the health sector. It has been argued that existing policy processes are mainly based on entrenched ideological positions and more attention should be paid to robust evidence of impact [ 101 ]. The UK developed policies focused on ’patient choice’ that allow people who are able and willing to choose to travel further for healthcare [ 102 ]. However, more robust policy making is still required to strengthen national health services and facilitate medical-health-wellness tourism sector development in destinations [ 103 , 104 ].

5. Discussion and Conclusions

5.1. generation discussion.

This study is based on a literature review of 802 articles on medical-health-wellness tourism from 1970 to 2020. Jeremy Snyder was found to be the most prolific author in this field with 45 articles. It has been found that the literature on this topic can be summarized into three themes: markets (tourist demand and behavior), destinations (development and promotion), and development environments (policies and impacts). The scholarly research in this growing field has undergone a shift in emphasis from tourist demand and behavior to the promotion and development of destinations, and, more recently, to policies and impacts.

To attract more tourists, destinations should explore their potential for medical-health-wellness tourism. Accessibility, procedural options, treatment facilities, travel arrangements, safety guarantees, and government policies remain influential factors. In the development and promotion of this form of tourism, childhood vaccinations, oral health, legal frameworks, evaluation systems, entrance systems, and macro-policy continue to be areas of concern and where further research is required. Above all, meeting or exceeding tourist expectations and requirements is the most important consideration to promote medical-health-wellness tourism. Similarly, appropriate policy guidelines and frameworks are necessary to support this form of tourism. Importantly, medical-health-wellness tourism may result in negative impacts on the healthcare service provision for local residents in poorer countries, with tourists from richer countries benefiting to the detriment of local communities. However, if managed successfully, this form of tourism can also be a force for good in terms of fostering the economic development of countries delivering these services.

The results indicated that the research literature is spread across a range of different disciplines and there is not one single venue for publishing in this field. A better integration of the research and improved understanding of the overlaps among medical, health, and wellness tourism is required.

5.2. Future Research Trends

5.2.1. industrial perspective.

Medical-health-wellness tourism will, over time, integrate fully with other healthcare and wellness services. Similarly, medical challenges such as disease prevention and traditional medicine remain essential directions for the future of health tourism. This form of tourism will also integrate further with industries such as wellness culinary tourism, mindfulness tourism, active tourism (including adventure tourism), and even cosmetic surgery tourism, leading to a vast array of potential research avenues linked to health tourism destinations. These futures will greatly promote the physical and mental health of wellness tourists. This is another emerging direction for future medical-health-wellness tourism research.

5.2.2. Destination Development Perspectives

Medical-health-wellness tourism will become more significant forms of tourism and impact the development of different nations and areas. For example, this tourism will integrate with Chinese traditional culture. Traditional treatments and remedies will become more of an advantage and should be a topic for future medical-health-wellness tourism research, as well as in other countries with unique health cultures, treatments, and procedures.

Thailand, Malaysia, and other Southeast Asian countries are favored by tourists from developed countries due to lower costs. In the future, these areas need to focus more on tourism product design, health tourism marketing, community participation, and cross-cultural communication. Developed countries such as the USA, Japan, and South Korea, will use advanced technology and medical equipment to take the path to high-end, high value-added tourism development. This will lead to some new research opportunities.

5.2.3. Tourist Perspectives

Compared with other types of tourists, the needs of medical-health-wellness tourists will receive more attention. Based on previous research, the psychology and perceived value of these tourists are the focus of considerable research. In the future, more emphasis will be paid to people and especially to their psychological and physiological needs. Research on demand will become a more popular topic of this tourism research. Second, the current research on medical-health-wellness tourists is concentrated on the study of tourists in the USA and Canada. Future research should be more dispersed and diversified. Tourists from emerging countries such as Eastern Europe, Asia, the Middle East, and Africa will receive more attention.

5.3. Limitations

This study, inevitably, has a number of limitations, including the relatively modest amount of articles collected. Only articles written in English were considered. The sample number is rather small to represent the general research trends in medical-health-wellness tourism from 1970 to 2020. Therefore, it is desirable to increase the number of publications and expand the time and language coverage of the research articles to gain more insights.

Although the research scope of medical-health-wellness tourism is vast, it lacks in-depth exploration. Current research is fragmented, lacks continuity and comprehensiveness, and therefore cannot be considered systematic. Also, the legal aspects of the development of this tourism, environmental capacity of medical-health tourism, wellness tourism management, and mechanisms of profit distribution for medical-health-wellness tourism are less frequently mentioned in research articles. Innovation in this field and international cooperation, and talent cultivation are also not sufficiently addressed. The methods used in medical-health-wellness tourism research are often simple. Scholars still use traditional descriptive statistics and related analysis methods. The theoretical foundation of medical-health-wellness tourism is still relatively weak. We are in the primary stage of this tourism research and in the development of related tourism products. People all over the world are eager for healthy lives. Medical-health-wellness tourism is likely to play a more important future role in travel medicine and tourism research. Beyond what has been done already, follow-up research should be focused on interdisciplinarity and based on the integration of industries. More theoretical research is necessary to support the future growth of medical-health-wellness tourism.

Author Contributions

Formal analysis, L.Z.; Funding acquisition, L.Z.; Investigation, L.Z.; Supervision, B.D.; Data collection and analysis, B.D.; Writing-original draft, A.M.M. and J.A.C.-S.; Writing—original draft, A.M.M.; Writing—review & editing, A.M.M., J.A.C.-S. and L.Y.; Data collection and analysis. All authors have read and agreed to the published version of the manuscript.

National Natural Science Foundation of China, Grant no: 71673015); Ethnic research project of the National Committee of the people’s Republic of China. NO: 2020-GMD-089; Fundamental Research Funds for the Central Universities of Beijing Foreign Studies University, 2021JS001.

Institutional Review Board Statement

No human subjects were involved in this research and no institutional review was required.

Informed Consent Statement

Not applicable as there were no human subjects.

Data Availability Statement

Conflicts of interest.

The authors have no conflict of interest.

Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

National Academies Press: OpenBook

Health and Wellness Programs for Commercial Drivers (2007)

Chapter: chapter 2 - review of the literature.

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52.1 Commercial Driving Affects Driver Health Addressing health and wellness concerns for commercial drivers is challenging, in part, because of the varied work environments in which commercial drivers operate. Some drivers may do daily deliveries of goods, while other drivers do short-haul or long-haul (over-the-road) delivery of freight. Bus and motorcoach drivers may drive passengers between distant cities and states or work in the tourist trade where the driver is more likely to usher passengers to tour stops and await completion of the passengers’ tour before making a return trip [for additional differences see CTBSSP Synthesis 6 (Grenzeback et al. 2005) and CTBSSP Synthesis 7 (Brock et al. 2005)]. How often, how far, and how long he/she drives, whether or not the driver works a regular schedule, returns home from an on-duty cycle every day, sleeps in his/her own bed, uses a truck sleeper berth while driving over-the-road, or sleeps in motels, eats regular scheduled meals, eats at home or in fast food restaurants, whether he/she has much opportunity to engage in physical exercise, and so on, all impact a driver’s state of health and wellness. From many aspects, the variety of work schedules of commercial truck and bus drivers is a major contributor to driver health and wellness concerns. Work schedules often may be irregular, involving long and unusual hours, and many drivers spend much time (successive days, even weeks at a stretch) on the road. When describing the myriad of factors involved in assessing commercial driver fatigue, McCallum et al. (2003) listed operational risk factors as including extended work and/or commuting periods; split- shift work schedules; changing, rotating, and unpredictable work schedules; lack of rest or nap periods during work; sleep deprivation and sleep disruption; sleep-work periods conflicting with the body’s biological and circadian rhythms; inadequate exercise opportunities; poor diet and nutrition; and environmental stressors. All of these factors make commercial drivers particularly prone to health problems. A driver’s chosen profession may predispose him/her to many of these health issues. A sedentary lifestyle, lack of good food choices, almost continuous exposure to whole- body vibration while driving, and numerous specific stressors such as driving in bad weather or heavy traffic are all condi- tions that can impact the driver’s health. In many cases, the driver’s chosen profession can lead to physical impairments that ultimately disqualify that driver from that profession. The National Institute for Occupational Safety and Health (NIOSH) uses Bureau of Labor Statistics (BLS) numbers to illustrate the incidence of deaths and injuries by occupation in the United States. For the 10-year period 1992 to 2001, BLS reported 479 fatal occupational injuries for truck drivers. The yearly rate ranged from 17.0 per 100,000 full-time workers in 1993 to a high of 39.2 in 1999. For truck drivers, BLS reported 57,999 nonfatal occupational injuries and illnesses involving days away from work during this 10-year period, and the rates varied from 533 per 10,000 full-time workers in 1992 to 359 in 1998—an average of 5,800 nonfatal cases per year (NIOSH 2004). Commercial drivers must adhere to federal regulations concerning fitness and suitability to drive. The relevant regulations are cited in Section 2.2. 2.2 Federal Regulations for Qualification, Fitness, and Suitability to Drive Physical requirements for commercial drivers are outlined under Title 49 of the CFR 391, the Subpart B, Qualification and Disqualification of Drivers: Paragraph 391.11 General Qualifications of Drivers. The list of requirements includes the following: “A person shall not drive a commercial motor vehicle unless he/she is qualified to drive a commercial motor C H A P T E R 2 Review of the Literature

vehicle.” Under Subpart E, Paragraph 391.41, Physical Qualifications and Examinations, specifies physical qualifica- tions for drivers as follows*: (a) A person shall not drive a commercial motor vehicle unless he/she is physically qualified to do so. . . .” (b) A person is physically qualified to drive a commercial motor vehicle if that person: • Has no loss of a foot, a leg, a hand, or an arm, or has been granted a skill performance evaluation certificate . . .” (follows with additional statements about hand, fingers, arms, feet or legs) • Has no established medical history or clinical diagnosis of diabetes mellitus currently requiring insulin for control; • Has no current clinical diagnosis of myocardial infarc- tion, angina pectoris, coronary insufficiency, thrombosis, or any other cardiovascular disease of a variety known to be accompanied by syncope, dyspnea, collapse, or con- gestive cardiac failure; • Has no established medical history or clinical diagno- sis of a respiratory dysfunction likely to interfere with his/her ability to control and drive a CMV safely; • Has no current clinical diagnosis of high blood pres- sure likely to interfere with his/her ability to operate a CMV safely; • Has no established medical history or clinical diagno- sis of rheumatic, arthritic, orthopedic, muscular, neu- romuscular, or vascular disease which interferes with his/her ability to control and operate a CMV safely; • Has no established medical history or clinical diagno- sis of epilepsy or any other condition which is likely to cause loss of consciousness or any loss of ability to control a CMV safely; • Has no mental, nervous, organic, or functional disease or psychiatric disorder likely to interfere with his/her ability to drive a CMV safely; • Has distant visual acuity of at least 20/40 (Snellen) in each eye without corrective lenses or visual acuity separately corrected to 20/40 (Snellen) or better with corrective lenses, distant binocular acuity of at least 20/40 (Snellen) in both eyes with or without corrective lenses, field of vision of at least 70º in the horizontal meridian in each eye, and the ability to recognize the colors of traffic signals and devices showing standard red, green, and amber; • First perceives a forced whispered voice in the better ear at not less than 5 feet with or without the use of a hearing aid, or if tested by use of an audiometric device, does not have an average hearing loss in the better ear greater than 40 decibels at 500 Hz, 1,000 Hz, and 2,000 Hz with or without a hearing aid; • Does not use a controlled substance identified in 21 CFR 1308.11 Schedule I, an amphetamine, a narcotic, or any other habit-forming drug; • Has no current clinical diagnosis of alcoholism. *For more details see FMCSA website at http://www.fmcsa. dot.gov. 2.3 FMCSA Initiatives Regarding Physical Qualification Standards FMCSA identified several health related areas where its standards are either outdated or lack application of the most current scientific and medical knowledge. The agency acknowledges that there are some cases where there is limited data to link the standards to driver performance and safety outcomes. FMCSA is working to address many of these medical and health related issues. Carriers are advised to track these issues when considering implementing a health and wellness program to ensure that the program addresses FMCSA’s health and driver qualification standards. FMCSA’s initiatives are detailed as follows (current through January 2007). 2.3.1 Medical Review Board Established In March 2006, the Secretary of Transportation appointed five medical experts to serve on FMCSA’s new Medical Review Board (MRB). The MRB will provide science-based guidance for establishing realistic and responsible medical standards during FMCSA’s planned updates to the physical qualification regulations for CMV drivers. Public meetings are planned to report and permit tracking of progress of the MRB. For details consult the FMCSA MRB website at http://www.mrb.fmcsa.dot.gov. 2.3.2 Research Panels Planned To support the work of standards revision and of the MRB’s review, research panels are being planned by FMCSA. 2.3.3 Chief Medical Examiner FMCSA has a plan to appoint a permanent Chief Medical Examiner as a full-time member of the FMCSA staff. 2.3.4 Certified Medical Examiners As part of the SAFETEA-LU Rulemakings under develop- ment, FMCSA issued a Notice of Proposed Rulemaking (NPRM) to establish a National Registry of Certified Medical Examiners (NRCME). The primary mission of the NRCME will be to improve highway safety by producing trained, certified medical examiners who can effectively determine if a CMV driver’s health meets FMCSA standards. 2.3.5 CDL and Medical Certification FMCSA’s proposed merger of Medical Certification and CDL Issuance and Renewal Processes (NPRM) was published 6

in the Federal Register (November 16, 2006, issue, Volume 71, No. 221 pages 66723–66748). The proposal would merge information from a driver’s medical certificate into the CDL process as required by section 215 of the Motor Carrier Safety Improvement Act of 1999. Section 215 of the Act would require interstate CDL holders subject to the physical qualification requirements of the FMCSA to provide a current original or copy of their medical examiner’s certificate to their State Driver Licensing Authority (SDLA). This information would be recorded on each individ- ual’s motor vehicle record (MVR) and subsequently be entered into the Commercial Driver License Information System (CDLIS), the electronic system that contains driver informa- tion for use by licensing and enforcement officials. 2.3.6 Hypertension Standard and Blood Pressure Criteria In 2004, FMCSA revised its standards for monitoring and diagnosing commercial drivers for signs of high blood pressure and hypertension to be more in line with the standards adhered to by the American Medical Association and the World Health Organization. The change in blood pressure (BP) criteria for CMV drivers was from BP < 160/90 to BP < 140/90. 2.3.7 Medical Standards Review On March 7, 2006, FMCSA announced the five medical experts who will serve on the new MRB. FMCSA is planning updates to physical qualification regulations of CMV drivers, and the board will provide the necessary science-based guid- ance to establish realistic and responsible medical standards. FMCSA and its MRB will work through the medical standards update process sequentially. The plans presently include examinations and possible changes to standards regarding diabetes, drug and alcohol, cardiovascular, neurol- ogy, vision, musculoskeletal considerations, and others. 2.3.8 Federal Vision Exemption Program As of January 2007, more than 1,000 active drivers were participating in vision exemptions as part of the FMCSA Vision Exemption Program. Additional clarification and updating of driver vision standards can be anticipated soon. Readers should check the FMCSA website for updated infor- mation on this activity. 2.3.9 Skill Performance Evaluation (SPE) The former Limb Waiver Program, now called Skill Perfor- mance Evaluation (SPE) Certificate Program, has more than 3,400 active driver participants. 2.3.10 Diabetes Standard In March 2006, FMCSA issued an Advance Notice of Public Rulemaking (ANPRM) regarding the Diabetes Standard. FMCSA announced that it is considering whether to amend its medical qualifications standards to allow the operation of CMVs in interstate commerce by drivers with insulin-treated diabetes mellitus (ITDM) whose physical conditions are adequate to allow them to operate safely and without deleterious effects on their health. Additional clarifi- cation of this standard is forthcoming. There has been a significant increase in applications since SAFETEA-LU was enacted. As of September 2006, more than 60 drivers have been approved for the Federal Diabetes Exemption Program. 2.3.11 HOS In response to the federal court ruling of July 2004, FMCSA provided supporting documents to the Final Rule on CMV Driver HOS, and also has forthcoming a set of Omnibus HOS Exemptions. There continue to be issues over the latest HOS regarding the definition of off-duty time, sleeper berth rules, interruptions of sleeper berth periods, and the use of a 34-hour restart counting the HOS rules. 2.4 Most Common Health and Fitness Risks for Commercial Drivers At an occupational health and safety conference held at Wayne State University, Saltzman and Belzer (2007) pointed out that occupational illnesses diminish the quality of life for truck drivers and may lead to premature death. They stated that substantial amounts of additional research are still needed on commercial driver health issues (Saltzman and Belzer 2002, 2007). Conference participants’ concerns about commercial driver health and wellness included • Poor health habits: It is estimated that more than 50% of commercial drivers are regular smokers. Many are obese, lack proper physical exercise, tend to develop chronic diseases such as diabetes at relatively early ages, and may have slightly elevated suicide rates. These points also are documented in studies of truck driver illnesses reviewed and cited by Roberts and York. • Driver injuries: About half of driver injuries involving lost workdays are attributable to sprains, often caused by overexertion such as lifting heavy objects (from Depart- ment of Labor job injury statistics). Most workers’ compensation injuries experienced in the moving, storage, and van lines sector of trucking today are attributable to 7

lifting and awkward posture movements while handling furniture and other items handled in moving and storage work. Studies of drivers loading and unloading cargo (Krueger and Van Hemel 2001) seem to corroborate those at-risk features of many truck driving jobs. • Driver fatigue: Sleep disorders, sleep loss, sleepiness, and driver fatigue from long and irregular work hours increase risks of operational errors, unsafe driving, injuries, and deaths. The NTSB, FMCSA, the American Trucking Asso- ciations, numerous safety advocates and the fatigue research community have documented extensively the issues and research surrounding commercial driver fatigue [see for example the review of many of these issues in CTBSSP Synthesis 9 by Orris et al. (2005); and extensive amounts of research on commercial driver cited on FMCSA’s website]. • Driver illnesses: Work-related environmental exposures (e.g., to diesel exhaust, other toxic fumes, continuous noise, and whole-body vibration) may be associated with chronic respiratory diseases, reductions in pulmonary function, lung cancer, allergic inflammation, hearing loss, musculoskeletal injuries, lower back pain, and other con- ditions which can have driving safety implications (Saltz- man and Belzer 2007). These same health risks were raised by Public Citizen in two successive federal court law suits (2004, 2005) as part of the continuing appeals of the newer HOS rules for truck drivers. A chapter in Transportation Research Circular E-C117 (Knipling 2007) produced by the Truck and Bus Safety Com- mittee (ANB70) outlines numerous health and wellness issues related to commercial driver safety (Krueger et al. 2007). Taken together, the chapter in the TRB circular, along with the CTB- SSP Synthesis 9 (Orris et al.) and the FMCSA-ATRI Gettin’ in Gear wellness program for commercial drivers (Roberts and York; Krueger and Brewster 2002) identify the most important and common risks to commercial driver health and fitness. • Regular tobacco use. It is generally believed that more than 50% of commercial truck drivers are regular tobacco users (Korelitz et al. 1993)—about double the national average of smoking adults in the United States (Substance Abuse and Mental Health Services Administration-Office of Applied Studies [SAMHSA-OAS] 2007). It is estimated that an employee who smokes costs an employer at least $1,000 extra per year in total excess direct and indirect health care costs (American Lung Association 2003). In the Stoohs et al. (1993) study of sleep apnea and hypertension with 125 truck drivers working for one company, 49% were smokers. The percentage of bus and motorcoach drivers who regularly use tobacco is generally believed to be slightly lower than that of truckers because of smoking restrictions inside passenger buses. Anecdotal reports from bus drivers indicate many bus and motorcoach drivers, as a result of such restrictions, have quit smoking altogether. • Being overweight and experiencing obesity. A survey of 3,000 commercial truck drivers in 1993 indicated more than 40% were overweight and 33% were obese. Both figures are con- siderably higher than national averages (Korelitz et al.). No current accurate figures were obtained on the incidence of obesity in commercial drivers. • Hypertension or high blood pressure. FMCSA recently revised CFR Part 391 standards for hypertension to con- form to those of the American Medical Association (AMA) and the World Health Organization (WHO). Now a driver with BP > 140/90 mmHg is deemed to have hypertension. If not treated, hypertension can lead to heart disease, renal failure, and stroke. No current incidence of hypertension figures was found for CMV drivers. However, the Korelitz et al. survey found 33% of drivers had BP > 140/90 and 11% had BP > 160/95. Such percentages indicate there is considerable room for improvement and add to the ration- ale that commercial driver health programs must focus on monitoring and preventing hypertension. • Poor eating and drinking habits, inadequate diet and nutrition. Many truck drivers admit to eating only one or two meals per day instead of the recommended three. Favorite main courses for meals on the road are still steaks and burgers, and many drivers eat numerous “junk food” snacks each day (Korelitz et al.). Few commercial drivers eat five or more servings of fruits and vegetables per day as recommended by the National Cancer Institute. Truck stop food choices tend not to be conducive to good nutrition. • Lack of physical activity and proper exercise, degrading states of physical fitness. Low physical activity is a major public health issue despite the considerable health benefits that can be gained from regular activity (Kelly 1999). Most long-haul drivers do not exercise regularly. Roberts and York reported that only about 10% of commercial drivers regularly participate in aerobic exercise; however, most attendees at the FMCSA-ATRI Gettin’ in Gear course offerings expressed much doubt that figures of regular aerobic exercisers are even that high. • Use and abuse of alcohol and other chemical substances, including misuse of prescription and non-prescription med- ications and drugs, diet pills, antihistamines, sleeping pills, energy drinks, and alleged nutritional food supplements. As a result of the implementation of randomized drug testing in the CMV work force and the threat of loss of employment if illicit drug use is detected, currently there does not appear to be a large problem with use and abuse of illicit drugs in the U.S. commercial driver population; however, no accu- rate figures on this problem were identified in this survey. 8

Figures on the use of alcohol and alcohol abuse also are not well-known in either the trucking or bus/motorcoach industries. Many drivers do not understand the impact a variety of other chemical substances have on health and driving performance. More research and education are needed on the performance and interactive effects (especially interactive effects) of prescription drugs, self- medications, and over-the-counter remedies such as antihistamines, diet pills, and nutrition supplements. 2.5 Health Issues That May Affect Commercial Driver Safety While these driver health risks can impact highway safety, many of the readily identifiable effects are more apparent on drivers’ quality of life and life expectancy (Husting 2006). Husting and Biddle outlined how commercial driving fits the Public Health Model, stating that motor vehicle safety is an important public health problem particularly involving commercial drivers. Solomon et al. (2004) point out that the workplace of commercial drivers is the community, and thus the health of commercial drivers is of special interest. Several studies suggest an association between illnesses among com- mercial drivers and the increased likelihood of fatal motor vehicle crashes with other drivers among the general public (NTSB 1990; Solomon et al.; Stoohs et al. 1994; Dionne et al. 1995; McCartt et al. 2000; Hehakkanen 2001). In a September 2006 review, a Joint Medical Association Task Force provided recommendations on sleep apnea screening for commercial drivers indicating the medical research they reviewed suggests obstructive sleep apnea is a significant cause of motor vehicle crashes (resulting in a twofold to sevenfold increase in risk) and increases the possibility of an individual having significant other health problems (Hartenbaum et al. 2006). 2.5.1 Cardiovascular and Heart Disease Cardiovascular disease, a leading cause of heart-related ill- ness and sudden death in the general population also impacts the health and safety of a growing number of commercial drivers in the United States (Rafnsson and Gunnarsdottir 1991; Bigert et al. 2003; Blumenthal et al. 2002). Only a few published studies directly address cardiovascular disease (CVD) as it affects truck and motorcoach drivers, and they provide mixed statements of its incidence and risks (Rafnsson and Gunnarsdottir; Bigert et al.; Blumenthal et al.; Robinson and Burnett 2005; Luepker and Smith 1978; Murphy 1991). Ruan Transportation Management Systems in Des Moines, Iowa, determined that during the 3 years of 1990 to 1992, heart problems appeared in the top two most expensive health care cost categories each year, and that more than 10% of the company’s total health care costs were related to heart disease. Truck drivers had most of the company’s heart claims and had a tremendous impact on Ruan’s employee benefit costs (Cleaves 1998; Holmes et al. 1996). Commercial drivers experience a unique constellation of risk factors for CVD involving lifestyle factors (i.e., poor diet, sedentary jobs, and smoking) combined with worksite factors such as long hours, vigorous exertion, strict road rules, stress, fatigue, and potential exposure to high noise levels, diesel fuel combustion exhaust, carbon monoxide, lead, freon, and the vast array of substances carried as cargo (Robinson and Burnett). Many factors common among truck drivers (elevated blood cholesterol, high blood pressure and hypertension, dia- betes, being overweight, lack of aerobic exercise, and tobacco use) contribute to chronic and acute cardiovascular illness that could lead to myocardial events while driving (Cox 1998; Roberts and York). As an example of this, an NTSB study of crashes involving truck driver fatalities reported 19 of 185 fatally injured truck drivers (10%) had such severe health problems that NTSB pinpointed health as a major factor in or the probable cause of the crashes (NTSB). Seventeen of those 19 crashes (89%) involved a form of cardiac incident at the time of the accident (e.g., sudden incapacitation of the driver due to an acute heart problem). 2.5.2 Diabetes During the past two decades, diabetes has become one of the most important public health problems—a consequence of increasing awareness and a dramatic increase in the number of people who receive a diagnosis of type 2 diabetes (Mantzoros 2006). Diabetes mellitus is a disease in which the body does not produce sufficient insulin, or does not metabolize glucose in the normal way, leading to metabolic changes that can have adverse effects. Diabetics have increased occurrence of eye disorders, kidney disease, arteriosclerosis, and heart disease. Poor circulation in the feet and legs attributable to diabetes leads to problems with peripheral nerves and vasculature of the extremities. One safety concern is that hypoglycemic episodes caused by diabetes may affect a person’s ability to drive. These episodes manifest through either loss of consciousness or disorientation, or from end-organ effects on vision, the heart, and particularly the feet. The main safety concern for insulin- dependent drivers is the possibility for unexpected occurrence of hypoglycemic reactions that cause drowsiness, impairment of perception or motor skills, abnormal behavior, impaired judgment (which may develop rapidly and result in loss of control of the vehicle), semi-consciousness, unconsciousness (diabetic coma), or insulin shock. Laberge-Nadeau et al. (1996) found CDL holders for single- unit trucks, who were diabetic, but without complications and 9

not using insulin, had an increased crash risk of 1.68 (i.e., 68% increased risk) compared with healthy CDL holders. As a result of irregular work schedules, rotating shifts, and night work that many commercial drivers experience, these drivers frequently experience circadian desynchronosis, a form of work shift lag (Comperatore and Krueger 1990) whereby normal circadian physiological functioning also shifts, some- times affecting other biological functions. Irregular work hours and resultant chronobiological considerations are important for diabetics and are especially critical for shift workers. Lack of sleep, fatigue, poor diet, emotional condi- tions, stress, and concomitant illness compound the problem by affecting the self-regulatory hormones that keep the blood glucose levels within normal limits. Commercial drivers who are diabetic need competent medical treatment and prescribed protocols for use of medications. These drivers must follow precautionary steps to avoid hypoglycemic episodes. Diabetic drivers must comply with specified periodic diabetes reviews by medical specialists; eat regularly timed carbohydrate-balanced meals to keep glucose levels within normal or desired limits; monitor blood glucose levels; carry supplemental glucose in the vehicle; and should stop driving immediately if a hypoglycemic episode occurs. As mentioned in Section 2.3, FMCSA currently has an active program in place to grant certain exceptions to dia- betic drivers and also to perform in-depth medical review of current research and insulin treatment practices for diabetics. 2.5.3 Hearing and Hearing Impairments An important safety consideration for drivers of commer- cial vehicles is the degree of responsiveness to critical events, particularly in crash-likely circumstances which call for employing defensive and evasive driving maneuvers. CMV drivers require a reasonable level of hearing to ensure their awareness of changes in engine or road noises that may signal developing problems. Drivers need good hearing awareness to respond to oncoming and overtaking traffic, to horns, to railroad crossings, and the signals and sirens of emergency vehicles. There is no medical requirement for commercial drivers to be able to communicate well through spoken word. Commu- nication requirements of a specific job may preclude such a driver from working for a particular employer, but medical criteria do not preclude certification for a CDL. As noted in Section 2.2, FMCSA currently requires all persons seeking a CDL to possess a certain minimal level of hearing. Hearing criteria in 49 CFR 391.41 (b) (11) state that a CMV driver cannot have an average hearing loss in the better ear greater than 40 decibels at 500 Hz, 1,000 Hz, and 2,000 Hz with or without a hearing aid or must be able to perceive a forced whisper from no less than 5 feet away. This actually means drivers with substantial amounts of hearing loss may be permitted to drive commercial vehicles. Most people with a significant hearing loss are aware of their disability. Hearing loss is gradual and insidious, and so people with mild hearing loss mostly are not aware of it. A driver with mild hearing loss often is able to compensate for his/her impaired hearing, even without wearing hearing aids, by being more cautious and relying more on visual cues. A moderate to substantial hearing loss does not appear to adversely affect a driver’s ability to drive safely when that driver compensates for his/her hearing loss by wearing pro- fessionally fitted hearing aids. After extensive literature review on topics related to hearing and driving, Robinson, Casali, and Lee (1997) estimated appropriate hearing levels required in driving commercial vehicles and evaluated methods to test drivers’ hearing. Results indicated some truck driving tasks require continual use of good hearing; that truck drivers could potentially suffer hearing loss from noise exposure; and that truck-cab noise in the 1990s model trucks studied compromised the intelligibility of live and CB speech, as well as the audibility of internal and external warning signals. Robinson, Casali, and Lee recom- mended several truck cab and warning signal design changes. In a field study to relate driver exposure to continuous acoustical noise to hearing loss, Seshagiri (1998) assessed the noise exposure in truck cabs by taking more than 400 meas- urements to determine the ambient noise levels to which truck operators are exposed while taking lengthy drives. Seshagiri took noise measurements at the driver’s head position in a variety of trucks (in long-haul, pickup and delivery, and sleeper berth truck samples) while drivers operated in a variety of driving conditions. Seshagiri found the noise exposures of 10% of the long-haul drivers tested exceeded 90 dB(A) while 53% of the average noise levels exceeded 85 dB(A). Seshagiri’s measurements indicate that some truck drivers, at least some of the time, incur a significant noise exposure risk to their hearing depending on the operating conditions, in particular when they routinely drive with the driver’s side window open and have the radio turned to a relatively high volume. The risk of hearing loss among drivers of repeated long- duration trips is therefore a health concern. While many newer truck cabs on the road today claim to have been designed to be quieter, there are no reports of recent acousti- cal noise measurements taken at the driver’s head position in Class 8 trucks. Because OSHA now promulgates workplace noise exposure limits approximating 85 dB(A) at the opera- tor’s head position, perhaps the 49 CFR 393.94 should be re-evaluated for sustained periods of truck driving and additional measurements of ambient noise in current truck 10

models should be collected and evaluated. There is also a need to develop an audiometric database for truck drivers, and presumably for bus and motorcoach drivers, and to continue assessment of the validity and in-practice application of the forced-whisper test, as well as to continue evaluation of active noise control systems (Maguire 2003, 2005) which can be used to reduce acoustical noise threats to the hearing of commercial drivers. 2.5.4 Vision Considerations Safe and proper operation of motor vehicles requires excel- lent vision, in terms of visual acuity, breath of visual field, and color vision. Good visual acuity is required for many driving tasks. A significant loss of visual acuity or loss of visual fields diminishes a person’s ability to drive safely. However, the level of vision necessary for safe driving has been a con- tentious issue because of the unavailability of definitive empirical evidence on which to base a clearly defensible visual performance standard (Decina and Breton 1993). It is gener- ally accepted that a driver with uncorrected visual defects (i.e., without prescription lenses) may fail to detect other vehicles, pedestrians, or roadside barriers, may take appre- ciably longer to read road signs at a distance or at night, and therefore may be slow to perceive and react to hazardous situations. Fortunately, prescription lenses can compensate for most forms of degraded visual acuity to permit most drivers to have adequate visual acuity for driving. Since the federal government began regulating vision stan- dards for motor carriers in interstate commerce during the late 1930s, the purpose of setting vision standards for drivers of commercial vehicles has been to identify individuals who represent an unreasonable and avoidable safety risk if allowed to drive CMVs. Federal regulations, specifically those covered by 49 CFR 391.41 (b) (10), require a driver to have distant visual acuity of at least 20/40 (measured via Snellen eye chart test) in each eye with or without corrective lenses, or visual acuity separately corrected to 20/40 (Snellen) or better with corrective lenses; and distant binocular acuity of at least 20/40 (Snellen) in both eyes with or without corrective lenses. Recently, laser eye surgery techniques have proliferated for vision corrections; however, laser surgery can be associated with several effects that bear on driver safety, including that of commercial drivers who have recently had laser eye surgery. According to the U.S. Food and Drug Administra- tion (FDA) Center for Devices and Radiological Health (2006) some patients who have had laser eye surgery have instability of visual acuity, which may decline during the waking hours. After undergoing this procedure some drivers may have different visual acuity at different times of the day, worsening by as much as two lines of the Snellen chart (which could result in visual acuity not meeting medical guidelines). Additionally, some people who undergo the vision correcting eye surgery procedure known as Lasik (laser-assisted in-situ keratomileusis) may experience glare, halos, and starbursts around lights at night, which could be troublesome while driving. The effects may take a few months to disappear. The vision medical guideline does not address these issues. It is not known how many commercial drivers undergo increas- ingly popular laser eye surgery for vision corrections. More research is needed on this set of visual issues relating to laser surgery outcomes. An aging driver population experiences vision changes associated with age, most particularly cataracts. Cataracts are opacities of the lens attributable to a biochemical change in structure in the eye. People with cataracts experience more glare, particularly at night when the headlights of oncoming traffic reflect off the cataract before hitting the retina. This results in loss of visual acuity and could result in difficulty perceiving the driving environment. Testing for this condi- tion is available, but not required in the Commercial Driver Examination (U.S. DOT vision medical standard). More research on the effect of cataracts and driving performance is warranted. An adequate visual field is important for driving, and peripheral vision is particularly important in tasks such as changing lanes, merging into a traffic stream, or detecting pedestrians about to cross into traffic. Severely restricted visual fields impair driving performance and can increase crash risk (Johnson and Keltner 1983; Wood and Troutbeck 1992, 1994; Coeckelbergh et al. 2004). U.S. DOT standards 49 CFR 391.41 (b) (10) require commercial drivers to have fields of vision of at least 70 degrees in the horizontal meridian in each eye. Decina and Breton suggest that this aspect of the standards should be revisited because the field-of-view of a normal healthy adult is closer to 140 degrees for each eye. Visual field losses can result from eye diseases such as retinitis pigmentosa (inherited degeneration of the retina causing significant visual field loss, often by age 30), or con- ditions such as glaucoma, optic atrophy, retinal detachment, or localized retinal or choroidal infection. Visual fields can also be reduced by head trauma, brain tumor, stroke, or cere- bral infection. Good rotation of the head and neck is also nec- essary to ensure an adequate field of vision. Drivers generally need good color vision for some driving tasks. CFR 49 391.41 (b) (10) requires a driver to recognize the colors of traffic signals and devices showing standard red, green, and amber. A driver with red-deficient vision would have some difficulty detecting and relating to red traffic lights at road intersections and in seeing rear braking lights on other vehicles. In effect, he/she would have to rely on see- ing the brightness of the lights rather than the red color. However, there is no solid evidence that color-blind drivers are less safe drivers. Recent improvements in traffic sign 11

engineering to modify the hue and intensity of traffic lights help persons with red deficiency. Decina and Breton point out that the color requirement does not exclude red-green color defective drivers because the standard does not provide adequate instruction on requirements for color vision test- ing. They also stated that it is doubtful that the standard intended to exclude typical red-green color defective drivers because these drivers are currently on the road and there is a lack of evidence that their safety record is worse than the records of those without such color vision defects. One of the problems with the standard is the lack of an adequate description of the specificity of testing stimuli, lighting con- ditions, equipment, or uniformity of testing procedures (Decina and Breton). This area too might warrant some additional research. Dark adaptation is important for night driving. “Night blind drivers” do not adapt well to darkness, can become involved in night driving crashes, and may need to be restricted to daytime driving activities. Driver testing does not check for night blindness conditions. Persons with progressive eye conditions such as cataracts, glaucoma, diabetic retinopathy, optic neuropathy and retini- tis pigmentosa require counseling by appropriate medical authorities and periodic checkups to determine if their eye conditions have worsened and progressed to the stage where they should no longer drive for safety reasons (Coeckelbergh et al.). Commercial drivers with such conditions may require encouragement to select another form of employment. Their vision should be monitored regularly, and when their loss of acuity or loss of visual fields is such that they are no longer safe to drive, they should surrender their CDLs and other driving licenses as well. If visual criteria are used to determine fitness to drive, sensitivity and specificity of the vision tests should be high. However, as Coeckelbergh et al. point out, numerous studies cited in the literature suggest that although the relationships between vision requirements and driving safety are signifi- cant, they are not conclusive with regard to the identification of individual at-risk drivers (Ball et al. 1993). For more information, see Visual Disorders and Commercial Drivers at http://www.fmcsa.dot.gov/rulesregs/ medreports.htm. 2.5.5 Sleep Disorders and Resultant Driver Fatigue Sleep disorders can deprive drivers of restful and restora- tive sleep in the necessary quality and quantity. Sleep disorders, all of which have independent health conse- quences, often lead to driver fatigue and loss of alertness while driving, thereby negatively affecting driving safety. Some sleep disorders particularly relevant to commercial drivers include insomnia, sleep apnea, drug-dependency insomnia, restless leg syndrome, delayed or advanced sleep phase syndrome, and narcolepsy. Krueger et al. (2007) provide a short explanation of each of these important sleep maladies. Sleep disorders individually are of concern because of the medical and health conditions associated with them. Obstructive sleep apnea, for example, interacts with inde- pendent related health risks involving respiratory, cardiovas- cular, and circulatory problems and increases the possibility of an individual having significant health problems such as hypertension, stroke, ischemic heart disease, and mood disorders (Hartenbaum et al.). For commercial driving safety, however, the resultant driver fatigue and adverse affects on commercial driver alertness on the road present the greatest concerns. Sleep disorders such as sleep apnea are diagnosable, treatable, and generally partially manageable for commercial drivers. There is an extensive literature on sleep apnea and its relationship to commercial driving (see Pack et al. 2000, Pack et al. 2002, and the FMCSA and National Sleep Foundation websites for some of this coverage). Through the efforts of the National Sleep Foundation, the FMCSA, and various safety- oriented groups, as well as sleep research groups, motor carriers have become increasingly more aware of sleep disor- der issues. Perspectives on sleep disorders, especially sleep apnea, have changed in the past decade. Some carriers have begun to develop sleep disorder countermeasures as a part of employee wellness programs. They provide medical screening for sleep maladies and provide for diagnosis and treatment (see the Schneider National case study in Section 4.1). The goal is to retain valuable, experienced drivers even as the driver receives treatment for sleep maladies. On September 12, 2006, a joint task force of the American College of Chest Physicians (ACCP), the American College of Occupational and Environmental Medicine (ACOEM), and the National Sleep Foundation released a set of new recom- mendations they claim offers an updated and consistent approach to the screening and management of obstructive apnea (OSA) among CMV operators (Joint Task Force press release, September 12, 2006; Hartenbaum et al.). This important Joint Task Force statement provides an updated description of sleep apnea, and bases its recommendations on an extensive review of the latest sleep apnea research and existing medical guidelines related to OSA from the U.S. DOT agencies. Readers will note that the research team chose not to cover the overall topic of commercial driver fatigue in this synthesis because this important topic is adequately covered in numerous other printed reports (for example, CTBSSP Synthesis 9 [Orris et al.]) and because many driver fatigue issues are more related to driving performance than they are 12

to “health concerns” per se. However, readers interested in worker fatigue as it relates to health issues might want to review a recent occupational medicine article by Ricci et al. (2007). They reported worker fatigue in the United States carried overall estimated costs of more than $136 billion per year in health-related lost productivity—$101 million more than for workers without fatigue (84% of the costs were related to reduced performance while at work, rather than absences). 2.6 Additional Driver Health Conditions That May Affect Driving Safety 2.6.1 Obesity Obesity refers to maintaining an excessive amount of body fat or excess storage of energy in adipose tissue. It is generally defined as a body weight greater than 5% more than the “ideal body weight” (average) for specific height and gender categories (McArdle et al. 1991). Medical personnel can readily identify health-related concerns for obesity in com- mercial drivers. They include a well-established risk factor for cardiovascular disease, hypertension, diabetes, or stroke (Roberts and York), and for obstructive sleep apnea (Pack et al. 2000; Pack, Dinges, and Maislin 2002). Obesity, or even being slightly overweight, exacerbates conditions of arthritis, back pain (particularly lower back pain), and other MSDs such as carpal tunnel syndrome (Miyamoto et al. 2000). Obesity also increases the risk of cancer when it accompanies other health-related conditions such as low activity levels, diabetes, or recent menopause. The AMA published “Assessment and Management of Adult Obesity: A Primer for Physicians” (Kushner 2003) in an attempt to encourage physicians to accentuate health promotion and disease reduction issues involving obesity. Research literature specifically relating obesity to driver safety and performance is scant and difficult to locate. Being substantially overweight and unable to maintain a healthy body weight and body fat levels interacts with a driver’s ability to maintain overall physical fitness and at least indirectly impacts on a driver’s ability to continuously maintain a safe driving posture and practices. In surveying 3,000 truck driv- ers, Korelitz et al. noted 73% were either overweight—body mass index (BMI) between 25 and 30—or obese—BMI greater than 30. Stoohs et al. (1994, 1995) reported a direct dose-dependent relationship between BMI and driver crash- likelihood. Obesity is often accompanied by obstructive sleep apnea, thereby contributing to driver fatigue. Stoohs et al. (1993) reported the prevalence of sleep apnea in 125 drivers working for one company they surveyed. Of those drivers with sleep apnea, 71% were borderline obese (i.e., defined as BMI > 28 in their study). The relationship between obesity and sleep apnea is a cause of health and safety concern among truck drivers because of the prevalence of obesity in this population. Obesity in the workforce is also of concern to employers who are interested in cutting down on workplace injuries and workers’ compensation claims that might be in part attributable to a worker’s overweight condition—seemingly a particular problem in the truck driver population of the United States. Since the 1960s, major changes in employ- ment protection in the form of antidiscrimination laws, such as the Americans with Disabilities Act (ADA), make it tougher for employers to enforce employee physical and weight standards, unless a person simply is unable to perform his or her job (Carpenter 2006). 2.6.2 Hypertension Hypertension or high blood pressure is a chronic disease affecting more than 50 million people in the United States. High blood pressure increases an individual’s risk of heart disease, renal failure, and stroke (David et al. 1996). Hyper- tension is called the “silent disease” or “silent killer” because there is no clear warning sign to an individual that he or she might have high blood pressure. It is very important for people to have their blood pressure measured and monitored from time to time, because they might have hypertension and not know it for months or years. Excess body weight correlates closely with increased blood pressure, and the survey work by Roberts and York found that almost every prospective study of factors that influence blood pressure regulation identified weight as the strongest predictor of blood pressure. David et al. estimated that in almost 50% of adults whose hypertension is managed through pharmaceuticals, the need for drug therapy could be alleviated with only modest reductions in body weight. In addition to the Korelitz et al. data cited in this report, there are other indicators that hypertension is a problem of considerable magnitude in the truck and bus driver commu- nities. An insurance industry study (Harrington 1995) indicated that 20% of the drivers in one of the test groups had high blood pressure. Evans (1994) reported that a large cross- sectional study of black and white male bus drivers in San Francisco revealed elevated rates of hypertension compared with a national sample of similar individuals. This study also noted the prevalence of hypertension increased with length of employment. Evans also reported a Norwegian study comparing male bus and truck drivers to industrial workers and noted a stronger correlation between length of employment and elevated blood pressure among commercial vehicle drivers 13

(Evans). The Stoohs et al. (1993) sleep apnea study reported 17% of the truck drivers in that 1993 study had blood pressures measuring greater than 160/95 mmHg. Contributing factors to hypertension include high cholesterol, obesity, and lack of exercise (West 2001). Uncon- trolled hypertension is the primary diagnosis for up to 25% of individuals with chronic kidney failure and can also be a major cause of strokes. Hypertension is very prevalent in African Americans and, according to the American Heart Association, up to 30% of all deaths in African American men can be attributed to hypertension. Fouad et al. (1997) describe the city of Birmingham, Alabama, as having almost 50% African American employees in their workforce, and therefore tailor their educational programs to target reduc- tions of hypertension as a significant part of health promotion. The program produced marked drops in blood pressure measures and demonstrated that a culturally appro- priate, educational program, focused on employees known to be at high risk, may increase control of hypertension. Hypertension, obviously one of the principal health risks to commercial drivers, is discussed at length in the FMCSA- ATRI Gettin’ in Gear train-the-trainer course (Krueger and Brewster). Course information for drivers stresses that: unlike vehicle diagnostic systems on trucks and buses, the body has no ready made gauge to tell a person he or she has high blood pressure. One of the easiest health and wellness suggestions to implement which is offered in that course is a suggestion for employers to acquire automated blood pres- sure monitoring cuffs/kits for their employees, especially so for their drivers. These can be purchased at almost any local drug store for approximately $50. The employer is then told to place the blood pressure monitors into the drivers’ day room or gathering place. They are also told to provide a basic amount of information about blood pressure and hyperten- sion (a supply of trifold brochures on blood pressure helps); and then suggest that from time-to-time their drivers meas- ure their own blood pressure and keep track of it in a personal diary for several consecutive weeks. If the drivers sense that they have suspiciously high blood pressure they should be encouraged to seek medical attention and advice. 2.6.3 Poor Nutrition, Eating Habits, and Diet It is a widely held belief that commercial drivers, both truck and bus/motorcoach drivers, do not usually adhere to healthy eating habits, and therefore their daily diet and nutritional needs are identified as a health and wellness concern (Roberts and York; Krueger and Brewster; Holmes et al.). The reasons for this concern include the fact that many commercial driv- ers are “continually on the go” driving from place to place. They consume much of the food they eat at “fast food restau- rants” or out of coin-operated vending machines and do not maintain a regularly scheduled nutritional diet program for themselves. For example, Holmes et al. studied 30 drivers in what they described as a prototypical wellness program. They pointed out that the drivers’ favorite meal items while on the road were steak and burgers. The typical snacks the drivers ate included chips, fruit, candy, donuts, and cookies, and only 15% of the drivers ate five or more servings of fruits and veg- etables per day as the National Cancer Institute recommends for preventive health purposes. In the Korelitz et al. survey of almost 3,000 truck drivers attending a trade show, more than 80% of these drivers ate only one or two meals per day, and 36% had three or more snacks per day. Roberts and York cited Dr. C. Everett Koop, who noted that 8 of the 10 the leading causes of death are related to what people eat. From heart disease to cancer, the food people eat has an influence on whether many chronic diseases develop. A healthy nutritious diet is among the most important influ- ences on an individual’s health. However, “bad habits” (eat- ing junk food, etc.) are among the hardest habits to change. Gettin’ in Gear points out that tracking one’s progress toward smoking cessation may simply be a somewhat easy matter of counting the decreasing number of cigarettes one smokes each day/week to gauge the degree of success one is having in smoking cessation. However, in terms of improv- ing nutrition, determining how much one consumes by counting calories, proteins, carbohydrates, vitamins, miner- als, and numerous other nutritional measures is considerably more difficult, because it requires a basic understanding of nutrition, the contents of food items consumed, and paying constant attention to the numbers—at least until healthy eat- ing becomes a good habit. Today, there is no shortage of nutritional information for the American consumer. This information includes books on the topic, newspaper, magazine, and website generated help- ful hints, improved labeling of the content and nutritional value of many consumable foods, the Department of Agricul- ture’s latest food pyramid (which is difficult to understand and use and seemingly requires access to computer descrip- tions of the details), the American Heart Association’s Healthy Heart symbols displayed on various restaurant menu items, and extensive lists of the contents of foods at many restaurants (including those provided in popular fast food restaurants). The Gettin’ in Gear training program begins the educational process for commercial drivers with plenty of insights on how to proceed (Roberts and York; Krueger and Brewster). 2.6.4 Sedentary Lifestyle: Lack of Physical Fitness There is plenty of medical and epidemiological research evidence to illustrate the value of physical activity, especially 14

in the form of physical exercise, to reduce the risk of many diseases, including cardiovascular and heart disease, hyper- tension, osteoporosis, diabetes, and breast and colon cancer, as well as reducing the risk of psychological illness such as depression, anxiety, and stress (Harig et al. 1995; Barko and Vaitkus 2000; McArdle et al. 1991; U.S. Department of Health and Human Services, Healthy People 2000; Lakka et al. 1994). A sedentary lifestyle, generally defined as one in which a per- son exercises less than once per week, is at least partially responsible for one-third of the deaths in the United States due to coronary heart disease, colon cancer, and diabetes (Lakka et al.; U.S. Department of Health and Human Services, Healthy People). It is estimated that about 30% of total deaths and 30% of total loss of disability-adjusted life years in the WHO Euro- pean Region are related to environmental and lifestyle factors which might be controlled or at least influenced through health protection and promotion activities undertaken at the work- place (Kelly). It is further estimated that physical inactivity is responsible for about 7 to 11% of deaths and 3 to 5% of total loss of disability-life years (Murray and Lopez 1996). Western European health and physical fitness figures are paralleled by many statistics in U.S. health industries. With a preponderance of irregular driving schedules, many commercial drivers, both truck and bus/motorcoach drivers, find it difficult to schedule time to do regular physical exercise. Fifty percent of the truck drivers in the Korelitz et al. survey of almost 3,000 drivers at a tradeshow said they never participated in “aerobic” exercises and only 8% of these drivers “regularly” participated in aerobic exercise. On the other hand, Halvorson (2002) found that regular exercisers at a company’s onsite fitness center achieved higher job performance ratings, stayed longer with the company, had lower medical and prescription claim expenses, and had lower absenteeism rates than those who did not exercise. Exercisers lost an average of 20.9 hours of work (per quarter) compared with 36.6 hours for non-exercisers. As with the difficulties in getting commercial drivers to eat nutritious meals, encouraging them to take opportunities to do regular scheduled physical exercises is tough. Having or making the time to do regular exercise is a chronic problem for many commercial drivers. A favorite line from one long- haul truck driver often quoted in the Gettin’ in Gear course is: “let me understand doc, I get off work about 3 a.m. and you expect me to go to the local gym and do what?” In the Gettin’ in Gear program, long-haul drivers are encouraged to capitalize on the opportunity to do 20 to 30 minutes of phys- ical exercise during their now mandatory 10 hours off-duty time since most people do not sleep for 10 hours straight. Numerous hints on how to prepare for and obtain necessary amounts of physical exercise both at home and while on the road, including identification of simple exercise equipment that can be carried in one’s truck or bus, are provided in the Gettin’ in Gear course materials (Krueger and Brewster; and see also Kelly; Cox 2003). 2.6.5 Musculoskeletal Disorders (MSDs), Low Back Pain, Neck Pain, Other MSDs, and Cumulative Trauma Disorders (CTDs) The U.S. Department of Labor’s Bureau of Labor Statistics (BLS) states that in the year 2004 there were a total of 1.3 mil- lion injuries and illnesses in private industry requiring recuperation away from work beyond the day of the incident. Four of 10 injuries and illnesses were sprains or strains, with most of these stemming from overexertion or falls on the same level. BLS also points out that in 2004, heavy-truck and tractor-trailer drivers suffered 17,770 MSDs, which was third highest among U.S. workers. Of the occupations with 0.75% or more of the total days away from work cases, drivers of both heavy trucks and tractor-trailer trucks, as well as light or deliv- ery truck drivers, had the highest median number of days away from work (12) because of illness and injury of all the occu- pations tracked. (See BLS: “Lost Work Time Injuries and Illnesses, 2004” www.bls.gov/news.release/pdf/osh2.pdf. ) Insurance industry figures on workers’ compensation perennially reflect numerous injuries for truck drivers as being involved with not only musculoskeletal injuries (such as low back pain), but neck, arm, shoulder, leg, and knee injuries (personal communication with Martin Lesko, Loss Prevention Manager at Vanliner Insurance Co., September, 26, 2006, at Dallas, TX). Obesity, or even being slightly overweight, is a large contributor to those injury statistics, as obesity can exacerbate conditions of arthritis, back pain, especially low back pain (Miyamoto et al.) and other MSDs such as carpel tunnel syndrome. Magnusson et al. studied the prevalence of back pain among 40 bus and 40 truck driv- ers, noting that 55% of the truck drivers were overweight. Truck drivers notoriously lead a sedentary life style (exer- cise less than one time per week) and their overall level of physical fitness is known not to be good, with large numbers of commercial truck drivers at least, bordering on being unfit. The picture for commercial bus and motorcoach drivers is less clear, because not much analytical data on their fitness levels was located. A Danish study in 1996 found almost all men in occupations involving professional driving had statistically significant elevated risks of being hospitalized with prolapsed cervical intervertebral disc (Jensen et al. 1996). In comparing occupa- tional risk factors, in 2003, the WHO listed the risks of experiencing low back pain by drivers of buses, trucks and tractors at a risk score ranging from 1.83 to 5.49 relative to a baseline risk of 1.0 for office clerical workers (Concha- Barrientos et al. 2003, pp. 1750 and 1784). The data source for 15

low back pain in this WHO report seems to have been data quoted from Bovenzi and Betta (1994). A literature review by Teschke et al. (1999) cited such factors as working postures, repeated lifting, heavy labor, previous back pain, and stress- related factors including job satisfaction and control, body condition, and weight (all associated with lengthy driving, at least some of these risks affect many truckers) as contributing to the incidence of back pain and back disorders in a work- force. Simple biomechanics explains why the human body’s natural curvature of the spinal column (lordosis) means that humans are not meant to remain in a seated posture for hours at a stretch, as the spinal fluid in the spinal column itself compresses over time while seated (Bhattacharya and McGlothin 1996). Teschke et al.’s data support a causal link between back disorders and driving occupations and whole-body vibration. Cann, Salmoni, and Eger (2004) highlight some of the contributions to back discomfort which can be attributed to whole-body vibration. At least, each of the major manufac- turers of truck seats offers air-cushion-ride seat features. Air- cushion-ride seats are known to absorb only about 20% of the whole-body vibration, so although those seats might feel more comfortable, they do not decrease whole-body vibra- tion influences all together. Thus, wellness programs such as Gettin’ in Gear need to stress to commercial drivers that they need to maintain a high level of physical fitness, manage and control their overall weight, select and adjust proper driver seating, and most of all take periodic breaks away from driving, during which they do some modest amount of exercises to break up the risk of MSDs attributable to back pain, or other CTDs such as carpal tunnel syndrome. A successful workplace ergonomics pro- gram can significantly reduce the number and types of mus- culoskeletal injuries (Grossman 2000; Tyler 2002, 2003). See also the TCRP Report 25 (You et al. 1997). 2.6.6 Psychological Stress and Mental Health Disorders Psychological stress. A dictionary definition of stress might include such things as “a mentally or emotionally dis- ruptive or disquieting influence causing distress.” According to Orris et al. (1997) this influence or stressor stimulates the sympathetic nervous system’s fight or flight response, neu- roendocrine secretion of corticosteroids, and consequent cardiovascular, hypertensive, gastrointestinal, and immune system impairments (see also Hancock and Desmond 2001). Stress-mediated immune system dysfunction may predispose individuals to arthritis, cancer, and autoimmune diseases. Many times a day, a person can experience stress-causing events that signal the body to produce numerous biochemical changes, mainly the hormones adrenaline and cortisol. A 1997 study examining psychological stress among 303 parcel deliv- ery drivers revealed these drivers scored significantly higher than the U.S. population on four common measures of job stress. This study (Orris et al. 1997) also noted these drivers had higher stress levels than 91% of the U.S. population on the best single scale of psychological stress (catecholamines). In another study among a paucity of such reports on commercial drivers, Evans and Carrere (1991) found a high degree of asso- ciation between exposure to peak traffic conditions and abnormal on-the-job levels of adrenal compounds in the urine of urban bus drivers. A NIOSH report, Stress at Work (1999), suggested that job stress can be defined as the harmful physical and emotional responses that occur when the requirements of the job do not match the capabilities, resources, or needs of the employee. The report says job stress poses a threat to employees’ health and in turn to the health of organizations. M. Mayer, a stress management expert states that stress levels in the workplace are getting worse as a result of poor management training and practices, feelings of a lack of control over the work environ- ment, and corporate cultures that value equipment over peo- ple (Mayer 2001). NIOSH indicates there is ample evidence some workplace stressors associated with overtime and extended work shifts may be correlated with various illnesses, injuries, and health behaviors. Overtime was associated with poorer perceived general health, increased injury rates, more illnesses, or increased mortality in 16 of 22 studies examined in a NIOSH review of work settings that included from health care work- ers, nuclear power plant operations, and electronics manu- facturing plants (Caruso et al. 2004). Four studies of extended work schedules reported the 9th to the 12th hours of work were associated with decreased alertness and increased fatigue, lower cognitive function, declines in vigilance, or increased injuries (Caruso et al.). Davis (2004) suggested that stress research shows that common tensions, whether the result of 50-hour work weeks, demanding supervisors, or personal concerns, can create a sense of unease or stress. Continuous high levels of stress can and do cause illness, poor judgment, nonproductive rela- tionships, and substandard performance. Experts in the stress management field point out that a given circumstance may be stressful to some people and not to others. That is, it is not the event that causes stress; rather it is the person’s reaction to the event that causes stress. Stress reactions vary, but they often include headaches, muscle tension, fatigue, insomnia, fuzzy thinking, and emotional, and other problems. Stress can increase the severity of already existing illnesses (Davis 2004; Tyler 2003; Goetzel 2005). Goetzel reviewed literature on the effects of stress in the workplace, both from an individual and an organizational 16

perspective. Goetzel indicated that when one couples indi- vidual health concerns with organizational stressors such as downsizing, lackluster senior management, poorly commu- nicated policies, and an environment without clear purpose, the potential for productivity losses can be pronounced. Personal stresses, along with job pressures and stresses may manifest as symptoms reflecting increased health, safety and productivity risks for the individual and the organization. Such symptoms may present themselves as medical condi- tions (e.g., chest and back pain, heart disease, gastrointestinal disorders, headaches, dizziness, weakness, repetitive motion injuries); psychological disorders (e.g., anxiety, aggression, irritability, apathy, boredom, depression, loneliness, fatigue, moodiness, insomnia); behavioral problems (e.g., accidents, drug and alcohol abuse, eating disorders, smoking); and organizational malaise (e.g., absence and tardiness, poor work relations, high turnover, low morale, job dissatisfaction, low productivity). In reporting on the costs of stress to the economy, Tyler (2003) and Davis (2004) quote figures from the American Institute of Stress (AIS), indicating that increasing costs of stress can be witnessed in the rapidly increasing cost of health care. In 2003, AIS estimated up to 90% of physician visits in the United States are probably stress related. The AIS quoted BLS statistics stating the median work absence attributable to stress was 23 days in 1997—more than four times the median absence for all occupational injuries and absences (Tyler 2003; Davis 2004). The AIS reported that stress costs U.S. businesses between $200 and $300 billion annually in lost productivity, increased workers’ compensation claims, turnover, and health care costs. Good Mental Health and Depression. The relationship between poor mental health and employers’ costs has been examined more recently (Goetzel). For example, a study by Goetzel et al. (1998) showed that employees who are depressed and highly stressed cost employers significantly more in health care costs compared with those without these psychosocial risk factors. Other studies documented the relationship between poor health and productivity losses (Simon et al., 2001). Clax- ton et al. (1999) demonstrated that when workers are appro- priately treated for depression, their absenteeism drops. The four most common mental health disorders are depression, bipolar disorder, generalized anxiety, and post- traumatic stress. Perhaps one of the least understood mental health disorders with its affects on job performance and health care costs is that of depression (Conti and Burton 1994). Davis reported the Society for Human Resource Man- agement (SHRM) estimated costs associated with depressive disorders are on the rise, and SHRM estimated depression costs employers from $30 to $40 billion each year (SHRM 1999). Although the costs of depression are high, the costs of untreated depression are much higher. When depression is not managed, employees may complain about a variety of physical problems. The SHRM report estimated up to 50% of all visits to primary care physicians are made because of conditions caused by or exacerbated by mental problems. The National Mental Health Association reported people with depression are four times more likely to suffer heart attacks than are those with no history of depression (Tyler 2002). Atkinson (2000) reported that employees who participated in a stress management program took fewer sick days than non-participating co-workers. Those who received stress management assistance saw doctors 34% less often than their fellow employees who did not get assistance. Atkinson concluded that a worksite program focusing on stress man- agement, along with education for small groups can reduce illness and the use of health care benefits. Teaching employees how to recognize stress reactions and the dangers and damag- ing effects of stress can be a powerful incentive for them to change their responses to the stress triggers in their lives. Tech- niques taught include deep-breathing exercises, guided imagery, and music therapy. Tyler (2003) reports that stress management programs have to be marketed so they show a link to the bottom line. Positioning stress management as a performance enhance- ment strategy and tracking results such as changes in productivity, absenteeism, turnover, and adverse incidents strengthens the credibility of stress management programs (Tyler 2003; Davis 2004). FMCSA 49 CFR 391.41 (b) (9) states that a person is qualified to drive a CMV if that person has no mental, nervous, organic, or functional disease or psychiatric disorder likely to interfere with his or her ability to drive a CMV safely. The reg- ulations go on to state that emotional or adjustment problems contribute directly to an individual’s level of memory, reason- ing, attention, and judgment. These problems often underlie physical disorders. A variety of functional disorders can cause drowsiness, dizziness, confusion, weakness, or paralysis that may lead to a lack of coordination, inattention, loss of func- tional control and susceptibility to crashes while driving. Phys- ical fatigue, headache, impaired coordination, recurring physical ailments, and chronic nagging pain may be present to such a degree that certification for commercial driving is inadvisable. FMCSA further states that somatic and psychoso- matic complaints should be thoroughly examined when deter- mining an individual’s overall fitness to drive. Disorders of a periodically incapacitating nature, even in the early stages of development, may warrant disqualification. (See the report on the Conference on Neurological Disorders and Commercial Drivers and the Conference on Psychiatric Disorders and Commercial Drivers http://www.fmcsa.dot.gov/rulesregs/ medreports.htm.) 17

In CTBSSP Synthesis 1, Knipling, Hickman and Bergoffen (2003) cited National Institute of Mental Health (NIMH) figures indicating about 22% of adult Americans suffer from a diagnosable mental disorder. Major disorders include depression, other mood disorders, and anxiety disorders such as panic disorder and obsessive-compulsive neurosis. In Knipling et al.’s survey work with the commercial truck and bus industry, these mental health problems were not per- ceived by carrier safety managers and other survey respon- dents to be as important as other topics in their safety management arena with commercial drivers. In research work related to the concerns over commercial drivers, Greiner et al. (1997) conducted 81 observational work analyses to measure stressors experienced by operators at the San Francisco Municipal Railway transit system. Greiner et al. defined stress factors as hindrances to task performance attrib- utable to poor work organization or technological design. Stressors included work barriers, defined as obstacles that cause extra work or unsafe behavior; time pressure; monoto- nous conditions; and time binding or control over timing. No other mental health related studies nor citable data specifically concerning the mental health of commercial driv- ers were located for inclusion in this section. Nevertheless, depression and other mental health adjustment disorders can be serious health threats and can have implications for high- way safety. The FMCSA-ATRI Gettin’ in Gear wellness program devotes a considerable amount of course material and class- room time to the topic of commercial driver stress and pro- vides numerous recommendations for stress avoidance and stress alleviation techniques and countermeasures, including provision of relaxation tapes, as part of the Gettin’ in Gear Four-R challenge geared toward Relaxing and Relating to others (Krueger and Brewster; Roberts and York). 2.6.7 Alcohol, Prescription Drugs, Over-the-Counter Medications, Other Chemicals Substance abuse is estimated to be the actual cause of approximately 120,000 deaths per year in the United States, with more 80% of them attributed to alcohol and around 20% attributed to other drug use. Alcohol and other drugs contribute to unintentional injury, suicide, and other violent deaths, and they are factors in a high percentage of chronic diseases (Healthy People 2000). According to the 2005 U.S. National Survey on Drug Use and Health’s National Find- ings, 19.7 million (8.1%) of the U.S. population used an illicit drug in the year 2005; 71.5 million (29.4%) used a tobacco product, and 126 million (51.8%) of Americans aged 22 and older used alcohol during the month prior to being surveyed (SAMHSA-OAS 2007). Safe-driving and the use of alcohol do not mix. For drivers who suffer from alcoholism, safe driving has become a huge public safety issue. For decades, annual U.S. DOT crash statistics reported alcohol was a factor in more than 40% of all traffic fatalities nationwide. The issues are of special con- cern to the commercial driver community. This is why the blood alcohol concentration (BAC) restrictions for commer- cial drivers are so much more strict for CMV operators (BAC 0.04) than for passenger car drivers (BAC < 0.08). So much has been written elsewhere about alcohol and driving, about driving performance under the influence of alcohol, and about the relationship of alcohol and the incidence of high- way crashes, that it is not focused on here. Alcohol use and commercial driving is an obvious safety issue and should also be viewed as a health and wellness issue. As for the incidence of alcohol and drug use by commer- cial drivers, Roberts and York summarized available reports as follows: • Crouch et al. (1993) studied the prevalence of drugs and alcohol in 168 fatally injured truck drivers and noted alco- hol was present in 12.5% of these drivers. Alcohol measures exceeded the legal limit of BAC 0.04% in 1% of these driv- ers. Marijuana was detected in 13%, cocaine was detected in 8%, and stimulants were detected in 11.3% of these cases. • In a Finnish study of 168 fatal-to-the-truck driver acci- dents from 1984–1989, Summal and Mikkola (1994) reported less than 1% of these drivers were found to be driving while intoxicated. • A 1986 study of 317 truck drivers randomly screened for drugs and alcohol in Tennessee revealed alcohol was pres- ent in less than 1% of these drivers; but 15% had evidence of marijuana, 2% had evidence of cocaine, and 15% had evidence of stimulants in their blood systems (Lund et al. 1988). • Korelitz et al. inquired almost 3,000 drivers attending a trucking trade show and determined 23% of all the drivers may have a drinking problem as indicated by their responses to questions regarding personal drinking perceptions. • An Australian study of 268 cited truck drivers revealed 15 to 18% of them had been convicted for driving while under the influence of drugs or alcohol (Hartley and Hassani 1994). • Crouch et al. reported a 1989 survey revealed 26% of drivers were perceived by their peers to be driving under the influence of drugs. Roberts and York expressed concerns over commercial drivers’ use of “heavy stimulants” because stimulants produce strong central nervous system stimulation and increasing physical and mental alertness. Citing the Physician’s Desk 18

Reference (1987), Roberts and York characterized amphet- amines as bringing about an elevation in blood pressure; however, the warnings include onset of increasing restlessness, dizziness, euphoria, and headaches as side effects, and state- ments that amphetamine use may impair the ability of a person to engage in potentially hazardous activities such as operating machinery or vehicles. Repeated use of amphet- amines can lead to drug dependence and can begin to cause irrational behavior, restlessness, anorexia, insomnia, agita- tion, tremors, increased motor activity, hallucinations, hostil- ity, and aggressive behavior (Pidetcha et al. 1995). FMCSA’s report to Congress on the Large Truck Crash Causation Study is an in-depth assessment of a nationally representative sample of large-truck fatal and injury crashes during 2001 to 2003 (FMCSA 2006). The report stated that among truck drivers, prescription drug use was an “associ- ated factor” in 28.7% of all crashes sampled, and over-the- counter drugs were an associated factor 19.4% of the time. FMCSA indicated an associated factor may not have con- tributed to a crash, but what was known is that the factors were present at the time of the crashes. Krueger et al. (2007) stated that at present, the commercial driving industry appears to have considerable control over illicit drug use in the employed work force. This is likely in part due to randomized urine testing of drivers for recreational and drugs of abuse and imposing harsh penalties such as loss of one’s job for positive test results; albeit some commercial driv- ers are still testing positive for such illicit drug use. Thus far, the only consensus agreement for allowable use of a stimulant by commercial drivers is that for consumption of caffeine and the many other stimulating substances similar to caffeine (e.g. guarana, taurine, etc.) found in energy booster products (drinks, food bars, chewing gum, etc.) commonly sold over- the-counter in health food stores, truck stops, and even grocery stores. Krueger et al. (2007) also reported that drivers sometimes take prescription or non-prescription medications, other chemical substances, and drugs (e.g. dietary pills, antihistamines, etc.): (1) as treatment for illnesses, or for relief from symptomatic ail- ments; (2) as self-administered countermeasures to fatigue (e.g. stimulants or hypnotics); or (3) for recreational purposes (e.g. alcohol, psychotropic substances). Some medications, or drugs, not only bring the driver relief from the discomfort and symptoms of various illnesses, or ailments, but such chemical substances also can have an impact on levels of driver alertness and therefore can affect driving performance and safety. Prescribed medications taken under a physician’s orders may treat some medical condition or ailment (e.g., drugs prescribed for hypertension, cholesterol control, heart conditions, depression, and other illnesses and conditions). Drivers may take a variety of prescriptions or over-the-counter non-prescription medications (e.g., sedating or non-sedating antihistamines, pain relievers) for treatment or relief from respiratory ailments like asthma, chronic bronchitis, emphy- sema, and seasonal allergies (e.g., hay fever, rhinitis; see Cockburn et al. 1999). Some drivers self-administer dietary supplements (weight loss or appetite suppressant pills); performance and mood enhancers, energy boosting drinks, pills, food bars, and other substances; stimulants (including caf- feine from various sources, and numerous other compounds that act in caffeine-like ways, e.g., guarana and taurine found in energy drinks); hypnotics (sleeping pills, melatonin); alcohol, and other chemical substances (Krueger et al. 2007). There is not enough scientific evidence on the performance effects of many such medications and the myriad of other chemical substances, either when administered singly, or in combination with others. The interactive and synergistic effects of many chemicals, medications, and drugs that drivers ingest are largely unknown. Some medications have side effects, and manufacturers are required to place caution warnings on the containers or on printed instructions inside drug packaging. Side effects for commercially available drugs are published in the Physicians’ Desk Reference; however, if the compound is not classified as a drug, but rather as a nutritional supplement (e.g., melatonin used as a sleep enhancer), then it is not governed by FDA good manufacturing practices and may not be written about in the Physician’s Desk Reference either. Any performance data and study results from pharmaceutical company research on such topics are not readily available because they are considered to be proprietary. Thus, the performance effects of many sub- stances, drugs, nutrients, and self-remedies, which drivers ingest are not so easily known (Krueger et al. 2007). This leads to concerns that not only does the driving community not have a good handle on the effects of mixing such chemicals in the body, but the physicians and health care providers who exam- ine, treat, or counsel commercial drivers also do not have com- mand of such information. 2.7 Medical Conditions, Functional Impairment, and Fitness to Drive While specific conditions such as diabetes, hypertension, and cardiovascular disease justifiably focus attention on medical fitness to drive, it is the impairment of key safe driving abilities that may result from these conditions that is of greatest concern. The aging of society, coupled with an increasing shortage of commercial vehicle drivers, defines an emerging priority: to develop a practical method of identify- ing impairments in the sensory, cognitive, and physical abilities that most strongly affect driving safety. Recent research indicates a relatively narrow array of specific visual, physical, and mental abilities that may provide the best crash 19

prediction. Such functional impairments are not specific to a medical condition (i.e., visual deficits can result from more than one disease). The research in this area has implications for opportunities to improve driver functional screening. A driver’s functional status is a more accurate measure of fitness to drive than medical diagnosis alone. A medical diagnosis is an important marker, but a disease may produce varying levels of impairment due to its particular manifesta- tion or stage of progression (i.e., diabetes and Alzheimer’s disease). Also, different diseases may result in comparable levels of functional impairment. This is reflected in reports from both the TRB and the Organisation for Economic Cooperation and Development (OECD) describing model licensing procedures that are based on functional assessment, rather than medical diagnosis, for the general driver popula- tion (TRB 2004; Aging and Transport 2001). Ensuring that requirements for commercial vehicle drivers reflect the latest evidence in this area is no less urgent. 2.7.1 Challenges Associated with Functional Requirements for CVOs Functional requirements for commercial operators are stated in 49 CFR Part 391, Subpart E-Physical Qualifications and Examinations. These pertain to vision [§391.41(b)(10)], hearing [§391.41(b)(11)], and certain aspects of limb and digit function [§391.41(b)(2)]. Supplementary “Medical Advisory Criteria” in this CFR provide physicians with addi- tional functional criteria for selected medical conditions. With this limited guidance, physicians are asked to certify that they have not detected “the presence of physical, mental, or organic conditions of such a character and extent as to affect the driver’s ability to operate a commercial motor vehicle safely,” nor any specific impairing conditions identified in the CFR (e.g., “has no current clinical diagnosis of alcoholism”). Only in selected areas are there well-defined requirements for a particular level of function for qualification to operate a commercial vehicle. Otherwise, the physician’s judgment determines when an impairment is severe enough to merit disqualification, when more extensive tests are needed, or when driver certification is restricted to a shorter period with a requirement to monitor and re-check. The AMA’s Council on Ethical and Judicial Affairs published recommendations addressing “physicians’ legal and ethical obligations with respect to reporting physical and men- tal conditions which may impair a patient’s ability to drive” (AMA 1999). The AMA underscored physicians’ traditional respect for the individual and desire to promote patient autonomy, while concurrently articulating the responsibility to recognize impairments in driving ability that pose a threat to public safety. Two criteria are paramount: (1) the physi- cian must be able to identify and document physical or mental impairments clearly related to driving ability and (2) the driver must pose a clear risk to public safety. 2.7.2 New Research Relative to Functional Abilities and Public Safety New research findings link indicators of public safety (crash risk) to objective levels of impairment in functional abilities. These findings can provide physicians with tools to satisfy legal and ethical responsibilities under the AMA, while meeting the intent of the federal regulations to certify a person is qualified to operate a commercial vehicle. The FMCSA establishment of an NRCME increases the impor- tance of disseminating this information. These examiners will apply a revised and standardized set of procedures in driver qualifications assessments. Recent research which focused on the cognitive abilities needed to drive safely appears to hold great promise. Decades of research on attention, perception, and cognition as related to crash occurrence led to a pilot test of an enhanced func- tional screening battery. This battery is aimed at enduring characteristics (sometimes referred to as “traits”) that is, the necessary focus of a screening instrument for driver licensure rather than transient performance-impairing factors, like fatigue, that may easily be remediated. The study was spon- sored by the National Highway Traffic Safety Administration (NHTSA 2005) and the National Institutes of Health/ National Institute on Aging (NIH/NIA) with cooperation of the Maryland Motor Vehicle Administration (Staplin et al. 2003). Full documentation of the pilot test is posted in the Model Driver Screening and Evaluation Program on the NHTSA website. This study demonstrated significant increases in the risk of at-fault crashes, based on police reports, with measured declines in four cognitive abilities. The study included a rep- resentative sample of nearly 2,000 drivers age 55 and older who were tracked over a prospective interval averaging 20 months per driver. Because cognitive decline is more likely among seniors, older drivers were of special interest in this study, but age was not an analysis variable (crash predictor). The loss of function, not age per se, was tied to increased risk of causing a crash. In this research, the strength of the relationships between functional status and crash causation was measured via odds ratio (OR) analyses. This method contrasts the odds of at- fault crash involvement with a measured decline in cognitive ability against the odds of crash involvement without such a decline. An OR value of 1.0 indicates a functional measure has no predictive value in screening at-risk drivers, while increasingly higher OR values denote more potent predictors. The cognitive abilities identified as significant predictors of at-fault crashes in the NHTSA study and associated OR values 20

are shown in Table 1. Measurement tools used to assess each cognitive ability are also indicated in this table. As is depicted in Table 1, four functional abilities have a significant impact on the odds of a future at-fault crash. Visu- alizing missing information enables drivers to perceive a whole object when only part can be discerned. This facilitates early recognition of emerging safety threats and anticipation of hazards. Drivers with this functional impairment were at nearly five times greater risk of causing a crash than drivers without it (see Table 1). Visual search is an important ability for rapidly scanning the roadway environment for traffic control information, navigational information, and potential conflicts with other vehicles, particularly in the vicinity of intersections. A visual search impairment resulted in a 3.5 times greater risk of caus- ing a crash (see Table 1). Working memory is a cognitive ability that enables drivers to remember and apply traffic regulations, route-following directions, delivery instructions, and other task-dependent information while simultaneously attending to current traf- fic and roadway conditions. Drivers with this functional impairment were at nearly three times greater risk of causing a crash than drivers without it (Table 1). The contribution of visual information processing speed to safe operations is demonstrated by an ability to detect threats at the edge of the “useful field of view” while maintaining concentra- tion on what is happening directly ahead. Drivers with visual information processing speed impairments were at roughly 2.5 times greater risk of causing a crash than other drivers (Table 1). This study focused on passenger vehicle drivers; however, the reported relationships between functional status and crash causation are not vehicle or situation specific. The cog- nitive abilities cited define performance domains with near- universal applicability in driving experience (including commercial). The same impairments should be cause for greater concern among commercial vehicle drivers. The larger sizes, heavier weights, and longer braking distances that define commercial vehicles increase task demands on com- mercial vehicle drivers relative to passenger vehicle drivers, while room for driver error is reduced because of the greater consequences of a crash. Also, at this time, there are no proven options for cognitive retraining or remediation of the deficits highlighted in the NHTSA/NIH/NIA research. The measurement tools employed in the pilot study included a combination of manual and computer-based tech- niques. To improve the reliability and standardization of the functional measures, while reducing cost and improving the efficiency of administration, currently computer-based tests are used for all of these cognitive screens. Clearly, this would also facilitate continuing this research or pilot implementa- tions of cognitive screening programs with motor carriers. 2.7.3 Additional Functional Criteria for CVO Qualifications The status of research findings related to other functional criteria for commercial driver qualification deserves re-exam- ination. In the area of vision, prior research has pointed to the need for clarification and expansion of the visual field require- ment. A FHWA study concluded the vision standard should be amended to require at least 120 degrees of visual field in each eye, measured separately in the horizontal meridian (Decina et al. 1991). This recommendation was strongly supported in a subsequent review conducted by Berson et al. 1998. Other research on vision—specifically, contrast sensitivity (CS)—and crash involvement also deserves mention. Whereas, acuity measures an individual’s ability to resolve fine detail (high spatial frequency information) that contrasts sharply with its background, CS measures the ability to dis- criminate objects with edges that may be poorly defined and that have low contrast with their background. Roadway debris encountered at twilight or a curb or median barrier without painted delineation, a pedestrian in dark clothing, are all examples of important low contrast targets. The poten- tial for safety gains from screening for contrast sensitivity in addition to standard acuity measurement has been demon- strated in analyses dating to at least the early 1990s (Decina et al.), and state DMVs (e.g., California) have begun to intro- duce CS in their passenger vehicle licensing operations on a pilot basis. However, research has not yet established a stan- dard of performance for CS for CVO qualifications. Hearing requirements for commercial operators were addressed in a case-control study of commercial drivers with hearing disorders (Songer et al. 1993) and in a human fac- tors study to evaluate the FHWA hearing requirement (Robinson et al.). As summarized in an FHWA Technical Brief (FHWA-OMC 1999), hearing is required to detect both intentional signals and incidental sounds to safely operate 21 Table 1. Peak valid odds ratios for significant at-fault crash predictors. Functional (cognitive) ability: Odds Measurement tool Visualizing missing information (visual closure): 4.96 Motor free visual perception test, visual closure subtest Visual search (with divided attention): 3.50 Trail-making test, Part B Working memory: 2.92 Cued and delayed recall (auditory) Visual information processing speed (with divided attention): 2.48 UFOV® subtest 2 Ratio

a commercial vehicle. In efforts to update current standards it is likely that the “forced-whisper” test methodology should be phased out of use, testing of commercial drivers should probably be done at a wider range of frequencies than are currently prescribed (up to 4,000 Hz), and the use of pure- tone audiometry to objectively assess hearing ability should be expanded. Where research has provided clear evidence to establish standards of vision and hearing performance for CVO quali- fications and associated measurement techniques, there is still a requirement to bring practice in line with these research findings. Initiating practical methods for driver screening for impairments in cognitive abilities that have been validated as predictors of at-fault crashes should yield further benefits for industry and for highway safety. Research should continue to provide the best possible information to those charged with updating the physical, medical, and fitness standards for commercial driving qualifications, so as to be able to address not only transient states, diseases, and medical conditions, but also the specific functional abilities research has linked to crash causation. 2.8 Corporate Employee Health and Wellness Programs 2.8.1 Why Corporate Health and Wellness Programs? Corporate America has experimented with employee health and wellness programs for more than a quarter of a century. The motivations for such programs include management’s humanitarian concern for the general well- being of employees and maintaining an aura of corporate excellence. More practical goals include stemming rising insurance premiums, health care costs, and workers’ com- pensation; decreasing incidents of injuries, deaths, costly accidents, and absenteeism; finding replacement employees while some workers are out; and ultimately improving bot- tom line profits for the company. In both the for-profit and non-profit (e.g., government employers) businesses, now more than ever before, corporate America seems to be embracing company-sponsored employee health and well- ness programs, primarily to slow down the ever-escalating medical care costs provided by employers. Improved recruit- ment, increased productivity, and improved morale are among other wellness program benefits. Over the past several decades, literally thousands of com- panies in the United States and western Europe initiated health and wellness programs, with varied degrees of success. However, many companies that implemented health and wellness programs also demonstrated vacillating levels of sustainment of such programs. Many of the programs dissipated back to “doing business as usual.” In preparing this synthesis, the research team identified a limited number of commercial trucking and bus/motorcoach companies with company sponsored health and wellness programs. It is one of the intentions of this synthesis to provide useful informa- tion and recommendations to assist the commercial shipping and passenger transportation industries with information for practical decision making regarding whether to proceed with their own health and wellness programs in hopes of improv- ing the lives of employees (commercial drivers) and impact- ing highway safety in a positive way. 2.8.2 What Constitutes a Corporate Health and Wellness Program? Several different “models” of corporate health and wellness programs might be described. The essential differ- ences among them are largely more a matter of degree of emphasis rather than differences in actual inclusiveness of the various elements of any good employee wellness program. This synthesis first reports some experiences gleaned from the literature on corporate experiences with different types of programs and highlights various elements of company wellness programs. It outlines a few select models of what a prospective wellness program might look like for the trucking and bus/motorcoach industries. For an extensive treatise of the cost-benefit analysis and organiza- tional strategies of health management programs, consult the University of Michigan Health Management Research Center’s Cost Benefit Analysis and Report–2006 (Edington 2006) and the work of Ron Goetzel for several decades of corporate wellness research that led to the current focus on Integrated Occupational Health, Safety and Health Promo- tion Programs in the Workplace (Goetzel 2005). Many pertinent peer-reviewed journal articles done by the staff at the University of Michigan’s Health Management Research Center describing work related to the topics of this synthesis are listed in the supplemental bibliography. There are numerous publications available in the health and wellness “industry or trade” on what to include and how to conduct workplace wellness programs. They are far too numerous to describe or even quote from them in this syn- thesis. For readers motivated to pursue this topic further, one publication which may be particularly pertinent and helpful is “Building Blocks for a Successful Workplace Wellness Program” (Huber et al. 2005). This volume serves as a primer for either wellness managers who are new to the field or for experienced managers who want a guidebook. It identifies numerous practical steps to take in beginning a program and explores elements, strategies, characteristics, and objectives employed in successful wellness programs. The compilation of sound advice, great ideas, proven methods, practical goals, 22

and “how-to” tips was produced by the editorial team from Wellness Program Management Advisor, a popular monthly news briefing for workplace wellness professionals. 2.8.3 Transportation Industry Employee Wellness Programs Roberts and York compiled a list of wellness programs in the trucking industry. A number of them are briefly described as follows: Ruan Transportation Management Systems. Holmes et al. and Roberts and York described the program of Ruan Transportation Management Systems, located in Des Moines, Iowa. In 1995, Ruan had more than 3,000 employ- ees to provide commercial vehicle and employee leasing services for private and for-hire trucking operations in 38 states. Ruan designed a wellness program for their com- mercial truck drivers as part of a management initiative to control rising health care costs. The company’s health care claims experience showed heart problems were the largest cost category for 2 of 3 observed years, and costs associated with heart disease represented more than 10% of total health care costs. In consultation with wellness specialists, Ruan first identi- fied the principal factors contributing to their employees’ heart problems: elevated blood cholesterol, elevated blood pressure, overweight employees, lack of exercise, and smok- ing. Since the first three of those risk factors are affected by nutrition, they sampled 300 drivers to determine their health and nutrition habits, by asking questions regarding meal and snack frequency and food selection choices while on the road. This survey revealed dinner as the most frequent meal eaten, and burgers and steaks as the most common meal of choice. Additionally, 48% of the drivers indicated snacking while on- the-road with potato chips as the most frequent snack choice. With the assistance of a nutritionist, the company’s man- agement team designed a nutrition intervention program and compared effectiveness of this program using a test and a control group of drivers to determine if a wellness program emphasizing driver nutrition could significantly affect the risk factors attributable to heart problems (Holmes et al.; Roberts and York). The program consisted of nutrition and wellness counseling, printed information designed to educate drivers about healthy meal choices, and “healthy snack bags” containing such items as fresh fruit, juices, raisins, pretzels, and fig cookies. The nutrition intervention program achieved significant differences among the test and the control group of drivers in areas of weight reduction, improved fitness level, and smoking cessation. The team also witnessed improve- ments in blood cholesterol levels, body fat, and blood glucose levels. Follow-up interviews with the drivers also noted improved feelings about the company (Holmes et al.). Roberts and York used telephone interviews of 23 trucking companies to elicit health and wellness program information (circa 1998–99). Only six trucking firms had or were willing to highlight their wellness programs. Roberts and York iden- tified these companies only by number in their report for FMCSA. The difficulties of establishing a wellness program in the commercial driver community are portrayed in the report and summarized here. Motor Carrier #1 was a truckload carrier in the United States with more than 14,000 drivers and 2,500 corporate staff members based in 15 operations centers around the United States. The company has a wellness program because of upper management interest and support. The corporate wellness coordinator indicated that cardiovascular claims were the number one medical cost for truck drivers, and that the company was implementing a disease management program, although specifics had yet to be determined. Other elements of the health and wellness program included a $30 reim- bursement for smoking cessation, an employee health assess- ment program, and stress management and aerobics classes. The wellness coordinator noted the program weakness was not reaching drivers or having wellness program representa- tives at local operations centers. The most extensive employee program participation was found at the corporate office where the wellness program was administered. Seventy-five percent of the operations centers were equipped with fitness rooms and employee cafeterias. Roberts (a dietician) reported that during her visit to one of these operations centers, there was no evidence of usage of the fitness room even though about 800 drivers passed through the facility each day. The majority of cafeteria food choices were typical high-fat menu choices such as bacon and eggs and hamburgers and cheeseburgers. Deli sandwiches and prepackaged salads were also available. At the time of Roberts’ visit (1999), the facility did not have a local wellness coordinator. Motor Carrier #2 was a for-hire flatbed operation with approximately 800 trucks. The company began a wellness program to keep health care costs down. However, Roberts and York observed the wellness coordinator had little under- standing of the company’s health care costs and had not ana- lyzed any data other than to know that costs were increasing. The wellness program reached primarily the office staff and not the drivers. It was estimated that more than $100 was spent on wellness per office staff employee, while almost nothing was spent on drivers. The company had a large fit- ness facility, cafeteria, and a motel at the corporate head- quarters. Lunch seminars, health assessments, and a newsletter were provided. It appeared there was little partic- ipation by drivers in the company wellness program. Weak- nesses were inability to reach drivers, newness of the wellness program, and lack of personnel to administer the program. 23

Motor Carrier #3 was a refrigerated carrier, with a large national operation and with 2,100 drivers and a staff of 300 operations and support staff personnel. Driver turnover rates reportedly exceeded 200%. The company was interested in wellness programs because the recently appointed president believed that health affects every part of the business. The company provided a $200 wellness benefit for all employees and distributed a health-oriented newsletter. However, at the time of the interviews, the company had not figured out how to effectively reach drivers with the wellness program. Motor Carrier #4 was a refrigerated carrier operating in all 50 states with an irregular route truckload operation. The company had 2,000 independent owner-operators and 400 in- house corporate staff support personnel. They too were in the beginning stages of developing a wellness program and at the time provided limited amounts of health information through a company newsletter. Flu shots, health screening, and fitness membership reimbursements were available to all employees and operators. The company was building a fitness center at the corporate headquarters. As with other trucking compa- nies, reaching the drivers was its biggest concern. This was reflected in participation rates—nearly 20% of corporate staff and only 1% of drivers participated in the company wellness program. Motor Carrier #5 was a private fleet operation consisting of 500 over-the-road refrigerated trucks. Four years previously, the company implemented a fatigue/health education pro- gram designed for its truck drivers. The program included classroom instruction on fatigue and other health issues and provided a manual containing information on exercise, diet, stress, and fatigue. The program demonstrated very positive results with a 40% reduction in accidents and large program acceptance by the drivers (Harrington 1995). As often hap- pens, the individual who developed, implemented, and championed the program left the company for a position elsewhere and, since the departure, the corporation reorgan- ized the fleet safety function, placing it under control of risk management, where the level of support by the company was far less. All program activities at the time of the interview were placed on hold. Motor Carrier #6 was a Western-based trucking company with approximately 3,000 truck drivers and 300 to 500 cor- porate employees. It attributed the more than 90% turnover rate primarily to the length of time truckers are away from their families. The company was building a new facility for their drivers to include sleeping quarters, a cafeteria, a the- ater, and a fitness center. In a desire to keep health care costs down, the company was giving high priority to employee health. The wellness program was initiated as a benefit for the employees. The program offered health fairs, weight management programs, exercise incentive programs, and lunch and learn sessions which brought in outside profession- als to speak on subjects such as diabetes, healthy food choices, and starting a fitness program. Other activities offered were golf, basketball, volleyball, and aerobics. A bulletin board with tips and facts on improving health was maintained. Truck drivers were told of the wellness programs during their orientation and were given a manual with information about stress management, healthy eating, and exercise tips. Nutri- tion packets were made available for drivers and included facts on healthy snacking and calories. The program’s participation rate averaged 20 to 25% of office employees and 10% of drivers. The coordinator did not think they had enough resources to reach more of the drivers. Roberts and York also described elements of an additional non-trucking company wellness program as follows: Grocery Retail Company is an employee-owned Midwest- ern grocery retail company with 35,000 employees, includ- ing 175 truck drivers. The company is decentralized with 250 locations in 7 states. The company placed much emphasis on employee health and started its own wellness program as a benefit for employees. It made the program available to all employees, their spouses, and retirees. Program activities which varied from location to location, often included seminars, recreational activities, and yearly health risk assessments-which were quite popular because they included medical testing of blood cholesterol, blood sugar, blood pressure, body fat, and fitness levels. After testing, a coun- selor explained the results and gave the employees or family members information and recommendations on how to improve their overall health. Follow-up contacts were made with high-risk employees to help in the behavior change process. The corporate office had “lunch and learns” cover- ing topics from osteoporosis and arthritis to healthy eating and safety issues. Every employee was provided a monthly health newsletter published by the company. The wellness program was staffed with a wellness coordinator, a consult- ant as needed, and five consultants for the health assessments and follow-ups. More than 75% of their full-time and regular-time employees participated in the health risk assess- ments, and participation in the overall wellness program was quite high. The company, which is self-insured, experienced a reduction in health care costs; employees also realized health care savings. Seven years passed with no increase in premiums and in 2 of the previous 10 years employees received a health insurance premium rebate. 2.8.4 Overall Benefits of Employee Health and Wellness Programs Davis said that the rising costs of health care today mirror those of the late 1980s and early 1990s, before managed care clamped down on health costs for a short time. In 2002, an HR consultancy firm estimated large employer (>100 employees) 24

costs at $4,026 per employee per year—three-fourths of the cost of premiums. Employees were estimated to pay an aver- age of $1,401 more in costs in 2002 than in 2001 (SHRM 2002). Gale (2002), a workplace health promotion specialist cited by Davis, estimated that, at most companies, 10% of all employees consume 80% of the health care costs. These are individuals at highest risk for conditions such as diabetes, high cholesterol, and heart disease, and they are the least likely employees to change unhealthful behaviors. Gale suggested the primary goal of any employee wellness program should be to return the highest risk people to low-risk status while help- ing the other 90% maintain a low health-risk lifestyle. How- ever, Gale noted that getting the 10% of high-risk employees to participate in managing their health and well-being can be a particularly challenging task. With these principles in mind, the staff at the University of Michigan Health Management Research Center points out that while high-risk individuals are often the targets of most health intervention programs, low-risk individuals often are allowed to live their lives with little or no apparent attention; and eventually they become susceptible to increas- ing risks without the proper attention to help them maintain their low-risk status. The premise of the Health Management Research Center therefore is to reduce the flow of low- or medium-risk individuals to high-risk which will result in reduction of the total of high-risk individuals within a few years. The important metric and the gold standard for suc- cess is the percentage of the population at low-risk (Edington). The Wellness Council of America (WELCOA), a nonprofit health promotion organization, is a leading provider of what it claims is a unique workplace wellness model—improving employee health and safety through deployment of its wellness coaches directly to the workplace. One of the goals is to empower employees and to get them to participate at significant levels in their company’s wellness programs and thereby achieve outstanding improvements in employee health. Some of WELCOA’s programs are outlined on its well- ness coaches website at http://www.wellnesscoachesusa.com. WELCOA suggests that although an employer cannot force employees to participate in a health and wellness pro- gram, the employer can tie such participation to an employee’s being able to participate in the employee benefits package. WELCOA estimated the typical benefits package costs a company expends is about $4,000 per employee, per year. Considering that outlay of expenditures, WELCOA believes a company has the right to ask individuals to, at a minimum, participate in a series of commonly provided health screenings or health risk appraisals. In addition, the company can implement targeted wellness programs, which are more likely to be used because people are more aware of their medical and health conditions following these screenings or appraisals (University of Michigan Health Management Research Center 1997 and 2006). Goetzel et al. (1998) followed approximately 46,000 employees from more than six large health care purchasers for 3 years after the employees had completed a health risk appraisal. Employees at high risk for poor health outcomes had significantly higher expenditures than did employees at lower risk in seven of ten risk categories: those who reported them- selves as depressed (70% higher expenditures), at high stress (46%), with high blood glucose levels (35%), at extremely high or low body weight (21%), former (20%) and current (14%) tobacco users, with high blood pressure (12%), and with sedentary lifestyle (10%). These same risk factors were found to be associated with a higher likelihood of having extremely high (outlier) expenditures. Employees with multiple risk pro- files for specific disease outcomes had higher expenditures than did those without these profiles for the following diseases: heart disease (228% higher expenditures), psychosocial problems (147%), and stroke (85%). The authors concluded common modifiable health risks are associated with short-term increases in the likelihood of incurring health expenditures and in the magnitude of those expenditures. A University of Michigan Health Management Research Center survey (1997 and 2006) of 1,035 major employers found that 85% of responding employers offer some form of health promotion, and 75% use health risk assessments. Incentives for employees making healthful lifestyle changes and the penalties for those engaging in high-risk behaviors, such as smoking, are becoming more prevalent. Health Management Research Center pointed out that a variety of factors associated with unhealthy employees can contribute to corporate costs including: absenteeism, medical expenses, distress to other employees during absences, and cost of replacement personnel. Davis concluded health promotion is typically approached in two ways: (1) decreasing external risks, such as by elimi- nating carcinogens and providing adequate on-the-job safety measures and (2) reversing risk behaviors, such as smoking and physical inactivity. The University of Michigan Health Management Research Center (1997) reported that DuPont found absenteeism 10% to 32% higher among its employees who had any of seven health risks: smoking, obesity, high cholesterol, high blood pressure, excessive alcohol use, lack of exercise, and not using seat belts. After implementing a well- ness program at 41 of its sites, DuPont had a 14% decrease in absenteeism. Davis also reported that the Health Manage- ment Research Center looked at the Union Pacific Railroad’s health promotion program, which was instituted when the company determined its medical costs per employee were almost twice the national average. After implementing a med- ical self-care program, Union Pacific experienced a savings of $1.26 million annually. 25

Davis reported the Daimler Chrysler/UAW wellness pro- gram realized a savings of $4.2 million among bargaining union employees who participated from 1999 to 2001. The program, piloted in 1985, had approximately 44,000 employ- ees participate from 1985 to 2004. Daimler Chrysler had more than 32,000 active participants in 2001. Daimler Chrysler contracts with health and fitness businesses to administer their wellness program, which is voluntary and confidential (Daimler Chrysler/UAW 2001). Their program activities are aimed at four goals: • Empower employees to be wise health care consumers and improve their health • Keep low-risk employees in the low-risk category • Target high-risk employees with focused interventions • Provide cost-effective wellness activities designed to con- tain health costs The Daimler Chrysler program employs the following incentives and techniques to increase and maintain employ- ees’ participation in the program: • Gifts distributed at health screenings • Well-bucks “money” earned for participating in activities that can be redeemed for prizes such as gym bags, sweat- pants, first aid kits, and polo shirts • Targeted marketing based on prior participation • Incentives for participating employees who bring in new participants • Convenient access to health screenings in the worksite • Interactive, fun, and non-threatening activities A study done of Johnson & Johnson’s large-scale wellness programs demonstrated positive long-term financial and health effects (Breslow et al. 1994; Davis 2004). The Johnson & Johnson study reviewed medical claims for more than 18,000 domestic wellness program participants from 1995 to 1999. Medical expenditures were evaluated for up to 5 years before and 4 years after the wellness program began. As a result of linking the program to health care benefits and finan- cial incentives, the company saw participation rise from 26% in 1995 to 90% during the study period. Financial incentives included a $500 medical plan discount for employees who completed a health risk assessment and, if recommended, enrolled in a high-risk intervention program. Employees par- ticipating in wellness activities had significantly lower medical costs and achieved improvements in several health risk factor reductions in 6 of 13 risk categories in the first year of the program: sedentary lifestyle, hypertension, high cholesterol, low dietary fiber intake, poor motor vehicle safety practices, and tobacco use/smoking. In the first 4 years of the program, Johnson & Johnson averaged $8.5 million savings annually. Savings came primarily from lower administrative and health care use costs (Johnson & Johnson 2002). In a brief examination of health and wellness programs in other segments of the transportation industry, TCRP Report 77 (McGlothin Davis, Inc., 2002) reported four health and wellness programs in the transit industry. • The Utah Transit Authority (UTA) in Salt Lake City, Utah. Since 1990, UTA has had a quality-of-life program called the Healthy UTA. Activities included sports programs, health evaluations for all employees and their spouses, a fitness facility at each worksite, health education, and discount tickets to recreational events in the community. In 2000, more than 1,000 employees participated in one or more of the wellness activities. • Metropolitan Area Rapid Transit Authority in Atlanta, Georgia. The program includes a twice per year health fair, monthly massages, brown-bag health education classes, monthly health promotion newsletters, and fitness facilities at each location. • Regional Transportation District in Denver, Colorado. The program, Champions of Transit, integrates community involvement, employee wellness and employee recognition activities, communicating its commitment to being a pos- itive force in the community and to its employee health, well-being, and development. • Pierce Transit in Tacoma, Washington. Health Express is an employee-committee program which sponsors health education and support to help employees make healthful lifestyle choices. 2.8.5 Other Findings of Interest Morris et al. (1999) pointed out that blue-collar workers are less likely to participate in worksite health promotion programs than are white-collar workers. Workers in a manufacturing setting, who engaged in welding, assembly, machine operation, maintenance, and painting, viewed the worksite health climate less positively than did white-collar workers. White-collar workers perceived more flexibility to exercise, a more healthful norm for nutrition, and more support from supervisors and co-workers for healthful behavior. Blue-collar workers had a higher norm on only one health behavior, that of an antismoking sentiment which was higher than that of the white-collar workers. Davis reported employers are increasingly implementing disease management (DM) programs as part of a health and wellness strategy to address the rising costs of treatment associated with chronic health conditions. Employers embrace DM as a way to improve the health of their employ- ees, boost productivity, and reduce medical insurance premiums. According to the Pharmacy Benefit Management 26

Institute, in 2001, 44% of employers offered DM for chronic medical conditions, up from 14% in 1995 (Atkinson 2001, 2002). Asthma, diabetes, and cardiovascular disease are the three major illnesses most commonly addressed by DM programs. The goal of DM is to ensure employees receive the best care possible and avoid complications. DM involves employees in their care, ensures proper treatment by physicians, and helps make sense of medical information. Often a contracted service, many DM programs focus not only on cutting health care costs, but also on improving employee attendance and ability to contribute at work. DM programs encourage employees to sign up with a health care provider who educates them about their diseases—how to manage them and the importance of proper medical care. DM programs hold down costs by providing employees and their caregivers with information on how to monitor and treat conditions and coordinate communication among the various stake- holders in the employee’s health care coverage (Atkinson 2001, 2002). Self-care and education efforts that focus on helping employees understand their illnesses and treatment are important aspects of DM programs. DM programs are some- times separated into three categories of service: (a) high-risk individuals who receive frequent telephone calls, as well as home visits or medical monitoring, (b) medium-risk indi- viduals who require frequent telephone contact, and (c) low- risk individuals who can get by with frequent mailings and occasional telephone contact (Atkinson 2002). Alan Pierce, a workers’ compensation attorney, prepared a top 10 list of reasons injured workers retain attorneys (Pierce 2002). The list is instructive in that it points the direction for employers to design portions of their employee wellness pro- grams in such a way that employers attend properly to the perceptions/expectations of their employees. They include 1. Workers’ compensation claim was denied. 2. There was no contact by the employer or the insurer with the injured employee. 3. There was overbearing or intrusive contact by the employer. 4. Bills went unpaid, prescriptions were un-reimbursed, or the check was late. 5. Lawyer advertising and solicitation caught the injured worker’s attention. 6. The advice of friends, family, or medical provider swayed the worker. 7. There was a lack of a modified-duty plan or harassment upon return to work. 8. Employee was dissatisfied. 9. Employee had loss of health insurance or other benefits. 10. The accident or injury should never have happened. 2.8.6 Does Workplace Drug Testing Reduce Employee Drug Use? Weed out Undesirables? In September 2006, the Substance Abuse and Mental Health Services Administration released its National Survey on Drug Use and Health (SAMHSA-OAS). Employers screen their workers and job applicants for drug use with the expectation that such testing will deter worker drug use. It is a cause-and-effect relationship that many employers rely on, and a belief that fuels a multibillion-dollar drug testing industry. When researchers at the University of California, Irvine (UCI), examined alternative explanations to test the link between employee drug testing and lower rates of employee substance abuse, the results did not definitively prove drug testing directly reduced drug use, but those results were the strongest evidence to date (Chris Carpenter of UCI, quoted in Occupational Health and Safety, Septem- ber 27, 2006; Carpenter 2007). According to the UCI study, other workplace drug policies, like a written “zero toler- ance” standard or employee assistance programs, do not explain away the association between testing and less worker drug use. The UCI study also considered the health profile of employees at worksites with lower drug-use rates to deter- mine if healthier workers self-select workplaces that are more likely to screen their employees. Because other policies and workforce characteristics likely dampen drug use to some degree, and because previous research did not account for those effects, Chris Carpenter said that past studies may have overstated the testing-drug use link. Carpenter said that fail- ing to account for other workplace characteristics and drug policies may bloat the testing-drug use association by as much as 25%. The researchers said that could be valuable information to budget-conscious personnel managers who are weighing the costs and benefits of establishing a drug- testing program. When the UCI study compiled data on marijuana screening at private, for-profit companies across the country, results mirrored previous studies, again indicat- ing marijuana is the drug appearing most often in employee failed drug tests. The implications of such research and commentary by the UCI researchers to the commercial transportation industry are not clear; however, the trucking and bus/motorcoach segments of industry impose no-tolerance and randomized testing for drugs in employees. 2.8.7 Criteria for Successful Employee Health and Wellness Programs For the FMCSA, Roberts and York surveyed numerous tenets of successful wellness programs (e.g., O’Donnel 1997; 27

Association for Fitness in Business 1992) and from them, extracted, adapted, and outlined the following fundamental elements for a successful company-sponsored employee health and wellness program: Fundamental Health and Wellness Program Elements • Commitment from senior management is important (highest level, CEO if possible) – Monetary and personnel support – Philosophical support – Participation in the programs • Clear statement of philosophy, purpose, and goals • Needs Assessment: survey the employee base, check health care costs • Strong program leadership • Use of effective and qualified professionals (e.g., wellness consultants) • Accurate, up-to-date, research-based information made available to participants • Effective communication – High visibility – Successful marketing – Motivating to employees • Accessible and convenient for employees (how to attract drivers) • Realistic budget • Fun, motivating, and challenging program philosophy • Supportive work/cultural environment – Company policies – Company attitude toward employee • Supportive physical environment – Cafeteria and vending provide healthy food choice options – Available fitness facilities – Windows, lighting, truck cab • Individualized to meet the needs of each employee • Defined evaluation system, establish criteria for success, changes • Shows results for the individual employees and the company Roberts and York provide extensive elaboration and expla- nation of most of these program elements, and readers are referred to those descriptions in the overall report by Roberts and York. That report can be found on the FMCSA website at www.fmcsa.dot.gov (publications). Many of the principles of the Roberts and York program development are embedded in the Gettin’ in Gear wellness program, and they appear in detail in the instructors’ manual and in the other train-the- trainer course materials distributed to course attendees (see Krueger and Brewster). 2.8.8 The New Paradigm: Integrated Occupational Health and Safety and Health Promotion Programs in the Workplace Goetzel (2005) describes a relatively new and emerging business strategy called Health and Productivity Manage- ment (HPM) aimed at improving the total value of human resource investments. Goetzel says HPM has been in the fore- front of advocating for integrated employee health, safety, and productivity management programs. These programs rely on the joint management of human resources benefits and programs that employees may access when they are sick, injured, or balancing work/life issues. They include health insurance, disability and workers’ compensation, employee assistance, paid sick leave, and occupational safety programs. Also included are activities meant to enhance morale, reduce turnover, and increase on-the-job productivity. Over the past 10 years, an integrated health, safety, and productivity model evolved. In part, businesses pursue an inte- grated approach as a business imperative because health benefits to employees have become increasingly worrisome. During 2000 to 2004, annual health insurance costs increased an average of 10 to 12% per year, and generally, additional increases are anticipated (Goetzel 2005). In 2003, the annual cost of providing health insurance benefits averaged $3,391 for employee-only coverage and $9,075 for family coverage. On average, employers paid 84% of the premium for employee-only coverage and 73% for family coverage (Gable 2003). However, Goetzel says when factoring in productivity related expenses, the costs to employers are significantly greater. Parry et al. (2004) estimated the overall health and productivity cost burden to employers averaged $16,091 in 2002. This included direct payments for health benefits and indirect payments attributable to lost productivity. Some expenses associated with lost productivity included hiring replacement workers when an employee is absent (absen- teeism) and reduction in services, loss of output and missed sales opportunities when employees are distracted or less attentive (e.g., an employee is at work but concerned about illness, etc.), especially when affected by poor health (presen- teeism). Workers in poor health, and those with behavioral risk factors, may cost the organization more than can be measured by adding up medical expenses; the spillover effects on other areas such as safety, morale, and productivity may be significant (Goetzel 2005). Goetzel et al. (2002) say that in many businesses, health, safety, and productivity issues are addressed separately, and discreetly, by different functions and departments in an organization: employee benefits, employee assistance, risk management, occupational medicine, safety, organizational development, operations, human resources, employee 28

relations, and labor relations. Fragmented, department-spe- cific strategies attempt to manage individual and organiza- tional risks although oftentimes these risks are common to several functions simultaneously within the organization and might be better managed through cooperative or integrated activities. Thus, HPM programs advocate an integrated health, safety, and productivity management model which establishes a new paradigm for working across departments to form a coordinated, synergistic, and unidirectional set of solution packages for both the employee and the company. This new paradigm forces managers to concentrate their efforts on improving the health and well-being of employees as a whole, not as individual cases, regardless of where the organizational benefit programs reside (Goetzel et al. 2003). This new and forward-looking approach to health and well- ness integrated across the organization is not easy and neces- sitates much organizational change, and hard work. (Consult Goetzel 2003 for details, especially his outline of the top 10 lessons learned in Health and Productivity Management (HPM) and Best Practices, pp. 34-39 and see Chapters 1, 5, and 10 in American College of Sports Medicine’s Designing Health Promotion Programs [Cox 2003]). 2.8.9 Commercial Driver Health, Wellness, and Fitness Training Programs A number of training programs have recently become available for encouraging and assisting commercial drivers to make health and wellness lifestyle changes, with a view toward maintaining and retaining a healthy workforce and fostering safe driving practices on the nation’s highways. Two such programs are highlighted here: the FMCSA-ATRI co- sponsored Gettin’ in Gear program and the Occupational Athletics program of driver athletes designed for commercial truck and bus drivers. Gettin’ in Gear Wellness Program. This program for commercial drivers focuses on principles of general wellness, health, and fitness for CMV drivers, for their employers, and for their families. The formulation of the Gettin’ in Gear wellness program was sponsored by the FMCSA, and it was initially developed by Susan Roberts (a dietician) and Jim York (a truck- ing safety officer) at the NPTC (Roberts and York). The Gettin’ in Gear program was further developed by ATRI. From the Get- tin’ in Gear program, the ATRI developed a 3-hour train-the- trainer course intended for commercial carrier staff personnel (e.g., human resources, occupational health, safety and risk managers, driver managers, and other company officials). Get- tin’ in Gear is also designed for presentation to truck and motor coach drivers themselves (Krueger and Brewster 2002; Brewster and Krueger 2005; Krueger, Brewster, and Alvarez 2002). The intent of the Gettin’ in Gear train-the-trainer course is to explain the most common health threats facing commercial drivers and to entice employers and drivers to take proactive action to participate in a personal wellness, health, and fitness program. The Gettin’ in Gear train-the-trainer course provides preliminary guidance on how to get started on such a program. An executive level Gettin’ in Gear course, normally offered to company officials, includes additional discussion of direct and the indirect health care costs associated with not having a corporate wellness program and addresses cost implications of implementing such a program. The Gettin’ in Gear program addresses lifestyle health risks associated with commercial driving careers. Important threats to commercial drivers’ health and fitness discussed in the course are as follows: • Smoking and tobacco use • Obesity/being overweight • Hypertension (high blood pressure) • Poor eating habits, poor diet and nutrition • Alcohol, drugs, other chemical substances • Lack of physical activity/physical fitness • Psychological stress and mental fitness Gettin’ in Gear provides preventive medicine guidance on what to do about these health risks and points the way to developing a personal wellness plan. Basic Gettin’ in Gear premises are as follows: • Drivers’ health behavior patterns are precursors to safe driving practices. • CMV driver health is important to ensure alert, attentive driving for overall safety on the nation’s highways. • Preventing health problems preserves the nation’s valuable CMV workers. • Driver wellness programs foster healthy employees, improve lifestyles, help contain health care consequences and costs for workers, their families, and employers, and they foster a positive corporate climate of concern and excellence. The Gettin’ in Gear wellness program is a personalized driver wellness program built around four health principles, called the four Rs of driver wellness. The 4-R Road Challenge is designed to help drivers attend to health and fitness matters while at home and while traveling on the road. The four Rs in Gettin’ in Gear are • Refueling: learning better eating practices so the body per- forms at its best, giving extra energy and better alertness, especially while driving. Offers nutrition information on lists of food and provides recommendations for healthy diets. 29

• Rejuvenating: improving one’s physical self through exer- cise, maintaining regular exercise and movement activities to preserve one’s health, and to remain physically fit. Sam- ple exercises drivers can do are described. • Relating: understanding the importance of relationships; and how to enhance relationships with others, both per- sonal and professional, as they impact our personal stress levels, our health, and our performance on the job. • Relaxing: becoming calmer in a fast paced world, at home and at work, by learning to recognize, control and manage our responses to the many stresses we face. Describes stress alleviation techniques, and hints to avoid road rage. For drivers, the Gettin’ in Gear wellness program is about the following: • Discovering an improved way of life • Finding one’s own optimal health • Experiencing one’s own personal journey • Having more energy, most of the time • Dealing with stress, anticipating it, managing responses to it • Feeling better about oneself, and just feeling good • Enjoying retirement, anticipating it rather than dreading it Drivers as Road Athletes. The Road Athlete System™ and the Bus Athlete System™ are two interactive driver health and safety training programs that specifically address the unique “roadblocks” facing truck and bus drivers that may prevent drivers from living a healthy lifestyle. This interactive training approach treats truck and bus operators as “road ath- letes” or “bus athletes,” encouraging participants to become involved in improving their own health and safety. Partici- pants are to imagine themselves as athletes, their playing field is the road, and they are to envision themselves as being the quarterback of their bus or truck. Each work day the drivers are to participate in a new game (outlined in a workbook) with a new opportunity to achieve personal health and safety goals. Participant drivers who become involved are given two audio CDs containing a motivational talk and a roundtable discussion among bus/truck drivers and safety experts focusing on the lifestyle and safety of professional drivers. Drivers are then given an Athlete System Game Book with 12 months of games (lessons) designed for the truck driver or bus operator to encourage them to make simple lifestyle changes in his/her own health and safety. Every workday, for 1 year, the book presents the bus or truck driver with another lifestyle and a safety factor along with short goals to accomplish. The 12 lifestyle factors covered in the driver athlete systems include nutrition, physical exercise, mental fitness, stress reduction, attitude and happiness, sleep, substance abuse, time management, motivation, disease prevention, weight/ obesity, and relaxation. The safety factors include weather conditions, driving regulations, passenger safety, compli- ance, pre- and post-trip inspections, injury prevention, and employee-employer relations. Each factor is accompanied by a “motor-vator” (a catch phrase) to increase driver interest in each topic. Daily tips and motor-vators are concise, easy to understand, and entertaining to read, and they express a day-by-day, step-by-step, and goal- by-goal approach to altering the driver’s lifestyle so as to be more healthy, and they encourage safe driving. Games include physical exercises, counting nutritional intake indicators, and stress reduction activities. As the drivers score their daily game goals, they become winners in the Game of Life. The intent of the road and bus athlete systems is to encourage commercial drivers to exercise control over their physical and mental well- being (lifestyle factors) and, at the same time, gain greater safety awareness and know-how (safety factors). These driver athlete health training systems were developed by Susan and Ron Shapiro and Mark and Lori Everest at Occupational Athletics, LLC, in Harrisburg, Pennsylvania (Shapiro 2005; Everest et al. 2005 www.occupationalathletics.com). The research team found that numerous trucking, bus, and transit companies are involving their drivers in these road athlete programs and beginning to report positive results. This approach warrants further scrutiny and monitoring to determine success rates. 2.8.10 OSHA Web-Based Assistance on Safety and Health Topics Recently, the Occupational, Safety and Health Adminis- tration (OSHA) posted on its website a Safety and Health Topics Page intended to provide information to help safety managers and others demonstrate the value—or “the bottom line”—of safety and health to management. More details about this OSHA initiative can be found in Appendix D. 30

TRB's Commercial Truck and Bus Safety Synthesis Program (CTBSSP) Synthesis 15: Health and Wellness Programs for Commercial Drivers explores health risks facing commercial truck and motorcoach drivers. The report examines the association between crash causation and functional impairments, elements of employee health and wellness programs that could be applied to commercial drivers, and existing trucking and motor coach employee health and wellness programs. In addition, the report includes several case studies on employee health and wellness programs in the truck and motorbus industries, focusing on the elements that appear to work effectively.

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    A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)—guided systematic review of the medical literature on health and wellness coaching allowed for compilation of data on specific features of the coaching interventions and background and training of coaches. Results:

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    Despite disparities in how health and wellness coaching have been operationalized previously, this systematic review observes an emerging consensus in what is referred to as health and wellness coaching; namely, a patient-centered process that is based upon behavior change theory and is delivered by …

  3. The Assessment and Measurement of Wellness in the Clinical Medical

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  6. A Systematic Review of the Literature on Health and Wellness Coaching

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