Using Total Worker Health® Concepts 

to Reduce Fatigue among Retail Workers

Summary

In recent years, retail workers in 

the United States have engaged 

in more shift work and longer 

work hours [Katz and Krueger 

2016; Greenhouse 2015]. These 

schedules can result in fatigue 

and related health issues. Through 

its Total Worker Health® (TWH) 

Program, the National Institute 

for Occupational Safety and 

Health (NIOSH) recommends an 

integrated approach to addressing 

fatigue in retail work. An integrated 

approach is one that protects 

workers from work-related injury 

and illness and helps them advance 

their overall health and well-being, 

on and off the job. The approach 

includes addressing factors that 

affect both the workplace and 

home life, including autonomy at 

work, workload, and environmental 

factors. This document describes 

organizational practices related to 

scheduling, flexibility, and the work 

environment that can help address 

the causes and consequences of 

fatigue among retail workers. 

The Nature of 

Retail Work

The retail trade sector includes nearly 

16 million workers in establishments 

that sell merchandise in small quantities to the public and perform services 

related to sales. Retail trade includes 

both store and non-store retailers; nonstore retailers reach customers through 

television, websites, portable stalls, 

etc. According to the Bureau of Labor 

Statistics, the retail trade injury/illness 

rate was 3.3 per 100 workers in 2016; 

whereas across private industry, the 

incidence rate was 2.9 per 100 workers. 

The retail trade measure known as daysaway-from-work (DAFW) had fewer 

reported cases than the Education and 

Health Care Sectors, but exceeded the 

number of DAFW that was reported 

for the Manufacturing Sector [BLS 

2016]. The retail sub-sectors with the 

highest rates of injury include stores 

that sell building materials and gardening equipment, general merchandise 

(department), food and beverages, and 

home furnishing [BLS 2015].

Retail businesses often have nonstandard and long hours of operation. 

Economic downturns and competition from online retailers have led to 

reduced staff as a cost cutting measure, 

and remaining staff often work longer 

hours or irregular shifts, or have additional workloads [Greenhouse 2015].*

Retail work is fast-paced and can 

involve heavy lifting and long periods 

of standing, leading to overexertion and 

musculoskeletal injuries† [NIOSH 2018; 

Anderson and Chun 2014]. These factors and trends in the retail industry can 

lead to fatigue.

Fatigue, Shift Work, 

and Health

Fatigue is the body’s response to short 

sleep duration, sleep cycle disruption, 

disturbances to circadian rhythms, or 

lengthy physical or mental exertion, 

which can result from long work hours, 

shift work, environmental factors, 

or heavy workloads [ACOEM 2012; 

Techera et al. 2016]. People also feel 

fatigue when their body is fighting off 

*

BLS [2005] data on the numbers of retail 

workers in shift work was last compiled in 2004; 

it shows that 16.3% of retail workers work shift 

work and night work, which is higher than the 

percentage for workers in all industries (14.8%). 

†

Although older workers have a lower overall 

injury rate, they are more affected by 

musculoskeletal injuries, since their recovery 

time is longer [NIOSH 2018]. For more 

information about productive aging and the 

workforce, visit https://www.cdc.gov/niosh/

topics/productiveaging/default.html
2

infectious organisms and when they have certain chronic 

diseases or take certain medications. 

Shift work can cause workers to sleep at irregular times 

or during daylight hours when their normal physiology is 

driving them to be awake and active. Sleep during daylight 

hours and after irregular shifts is generally shorter and less 

refreshing than sleep at night [NIOSH 1997]. Long work 

hours may not allow enough time between work shifts to 

get enough sleep [ACOEM 2012]. Most adults need 7 or 

more hours of sleep each day for optimal health and safety 

[Mukherjee et al. 2015]. 

Sleep cycle disruption and short sleep duration can also result 

from pain, certain medications, stress, insomnia, and other 

sleep disorders [NORA Sector Council 2016; Techera et al. 

2016; ACOEM 2012; National Sleep Foundation 2015]. Sleep 

disorders are common but they are often not identified and 

treated [Colten and Altevogt 2006]. Another source of sleep 

disturbance is caring for infants or other family members: 

this can make it difficult for workers to get enough sleep and 

cause them to feel fatigued.

Workers with fatigue report more physical health problems, 

role limitations, and poorer general health and social functioning [NORA Sector Council 2016; OSHA n.d.]. Shift 

workers have a higher risk of digestive disorders, metabolic 

disorders, cardiovascular disease, psychological disorders, 

cancer, and type 2 diabetes. They can also experience adverse 

reproductive outcomes including reduced fertility, pre-term 

birth, and miscarriages [Caruso 2014; ANSES 2016]. Shift 

work and long work hours are associated with poor health 

behaviors such as smoking, alcohol use, and a lack of physical 

activity [NIOSH 2004; Caruso 2014].

Fatigue and Work Performance

Risk factors for occupational fatigue include long work hours, 

heavy workload, job stress, working late evening hours, 

night work, and irregular shifts [NIOSH 1997, 2002; NORA 

Sector Council 2016; Techera et al. 2016]. Exposure to environmental factors at work such as excessive noise, extreme 

temperatures, poor lighting, poor air quality, and vibration 

may also cause fatigue [NIOSH 1997; Techera et al. 2016]. Not 

getting enough breaks during the work shift also increases the 

risk for fatigue. In addition, workers may become fatigued if 

they do not drink enough fluids and eat enough nutritious 

food at regular intervals during the work shift.

Fatigue resulting from nonstandard or extended shifts can 

affect cognitive ability and function; reduced functioning 

results in slower reaction time and more errors on the job. 

Errors on the job can compromise safety and cause more 

injuries [NIOSH 1997, 2012a,b; Caruso 2014]. Fatiguerelated incidents are related to time of day, with an increased 

risk in the early morning hours (about 4 to 6 A.M.) when the 

urge to sleep is at its peak [ACOEM 2012]. The middle of the 

afternoon is another time when workers are prone to feeling 

sleepy and may make errors.

The risk of fatigue-related injuries increases with evening and 

night shift work, and as more consecutive hours and consecutive nightshifts are worked [Techera et al. 2016]. Studies on 

the effects of extended shifts report that the 9th to 12th hours 

of work are associated with decreased alertness, increased 

fatigue, lower cognitive function, declines in vigilance, and 

increased injuries [NIOSH 2004]. Decreased alertness also 

affects productivity, because fatigue increases the time it takes 

to accomplish tasks [NORA Sector Council 2016].

Although specific industries have guidelines to limit shifts 

or to provide minimum time between shifts, no U.S. federal 

regulations limit shift length or specify a minimum number 

of hours between shifts for the majority of workers, including 

those in retail.‡ The Department of Labor defines limits on the 

number of hours that youth under 16 can work [DOL n.d.]. 

Fatigue in the Retail Industry

Trends in the retail industry include irregular and extended 

shifts and reduced staff. Understaffing may mean that only 

a few core remaining employees are able to close one shift 

and open the next; they may also have to take on additional 

workloads. More overtime and heavier workloads for remaining employees can lead to overexertion, stress, fatigue, and 

more turnover [Anderson and Chun 2014; Greenhouse 

2015; ACOEM 2012; Katz and Krueger 2016]. Overexertion 

(and fatigue) can also result from long periods of standing, 

time pressure, and lifting merchandise [Anderson and Chun 

2014]. Forty-two percent of store and other retail workers 

noted that their job has a negative effect on their level of stress 

[Harvard School of Public Health 2016]. 

According to the National Health Interview Survey [NIOSH 

2015a], more than half of retail employees work nonstandard 

shifts or work weeks longer than 48 hours; food and beverage 

workers are particularly affected. Half of retail workers know 

their schedules only a week or less in advance [Lambert et 

al. 2014]. The growing percentage of workers who are temporary, on call, or under contract shows that this trend is 

increasing [Katz and Krueger 2016]. Uncertain scheduling, 

heavy workloads, and overexertion among retail workers may 

be more acute during peak seasonal periods. When workers 

have less control over schedules and workloads, they have less 

autonomy at work.

‡The U.S Department of Transportation regulates hours of service for 

all the commercial transportation modes. The U.S. Nuclear Regulatory 

Commission regulates work hours for nuclear power plants. Some states 

ban mandatory overtime in registered nurses [OSHA n.d.].
3

Total Worker Health®:

an Integrated Approach

Total Worker Health® approaches are defined as policies, 

programs, and practices that integrate protection from workrelated safety and health hazards with promotion of injury 

and illness prevention efforts in order to advance employee 

well-being [NIOSH 2015b]. According to research on TWH, 

comprehensive practices and policies that take into account 

the work environment (both physical and organizational), 

while also addressing personal health risks, are more effective 

in preventing disease and promoting safety and health than 

each approach taken separately [NIOSH 2015b; Sorensen et 

al. 2013]. Traditional workplace safety and health programs 

have concentrated on the safety of the work itself and on protection from exposure. 

Traditional health promotion programs have promoted personal health and individual interventions separately from 

issues related to work. But TWH recognizes how work itself 

is a determinant of health and how factors such as stress, 

workload, autonomy, and hours of work and rest can influence health outcomes [NIOSH 2015b; Schulte et al. 2007].

Organizational Support for Total 

Worker Health®

TWH prioritizes organizational-level policies, programs, 

and practices designed to protect workers and improve their 

health [NIOSH 2015b]. Organizations can lead through 

example and support positive influences within the work 

environment to help decrease fatigue among employees. 

This type of support may include developing and implementing a fatigue risk management system [see NIOSH 2015c

and ACOEM 2012 for elements of a fatigue risk management system].

Retail employers should be aware that workers may take 

extra shifts or work an extra job to make ends meet, or be 

awake after a night shift to attend classes or take care of family 

[Techera et al. 2016; Greenhouse 2015]. Those who work 

night shifts may sleep when the surrounding environment is 

noisier and more disruptive. These issues need to be considered when workers’ schedules are made.

Long hours and resulting fatigue may limit the opportunity to 

pursue other health-enhancing or health-promoting activities 

and may limit time spent with friends and family. As noted by 

Schulte et al. [2015], true well-being requires that workplaces 

adopt a comprehensive approach to worker health and safety.

Benefits of Total Worker Health®

Although TWH emphasizes that the safety, health, and wellbeing of the worker are of primary importance, providing 

opportunities for promoting worker health (such as allowing for adequate rest and time between work shifts) also has 

benefits to the employer. These benefits can be direct, such as 

the reduction of health-related expenditures and absenteeism, as well as indirect, such as improved employee morale, 

advantages in recruitment and retention, and even reduced 

injury rates [Fabius et al. 2013]. Employers, workers, their 

families, and communities all benefit from improved health, 

disease prevention, and work productivity that can result 

from adequate amounts of sleep and reduced fatigue [NORA 

Sector Council 2016].

When implementing these policies and systems in support 

of TWH, retail employers should consider both work-related 

and individual factors to reduce fatigue and improve worker 

safety, health, and well-being.

Recommendations for 

Incorporating Total Worker 

Health® Concepts into Workplace 

Safety and Health Programs

Because of the potentially higher health and safety risks as 

well as risks of decrements in performance associated with 

night shifts, retail managers can consider whether they are 

able to eliminate or modify night shifts and move the work 

to daytime hours (for example, 7 A.M. to 11 P.M.). Employers 

monkeybusinessimages/iStock/Getty Images Plus/Getty Images
4

should also consider the following TWH concepts to reduce 

worker fatigue [NIOSH 1997, 2012, 2014, 2015c; CDC 

2012; 2014; Schulte et al. 2015; ACOEM 2012; Goetzel and 

Ozminkowski 2008; Goetzel et al. 2014; AHA 2014]:

 Implement a fatigue risk management system that is 

supported by research, has stakeholder input, and includes 

incident reporting. (NIOSH has developed strategies 

for designing work schedules and workloads in Part 

2, Module 5 of publication 2015-115.) (The American 

College of Occupational and Environmental Medicine 

also has information about implementing a fatigue risk 

management system [ACOEM 2012].) 

 Offer workers more job autonomy and control over 

schedules, job tasks, and other conditions of work. 

 Consider shortening work shifts that involve heavy 

workloads, or redistributing heavy workloads to times 

when workers are more alert.

 Ensure that any program striving to advance worker 

safety, health, and well-being has the commitment of 

organizational leadership, support from all levels of 

management, and worker participation and input.

 Involve workers and labor representatives in designing and 

implementing procedures and practices to reduce fatigue.

 Include health education (information dissemination and 

awareness) about the effects of fatigue, managing sleep 

disorders, and coping with shift work (in combination with 

the policies, programs, and practices that allow workers to 

adjust conditions of work to minimize fatigue).

 Link existing worker safety and health programs to related 

programs such as counseling or employee assistance 

programs and related training efforts [OPM n.d.].

 Evaluate existing resources and current policies, programs, 

and practices to assess what is effective in promoting 

autonomy, determining work schedules and workloads 

that promote good health, and promoting other conditions 

that minimize fatigue.

 Promote the importance of sleep and let workers know 

what resources are available to help them.

 Design the work environment to minimize noise 

and vibration. Ensure adequate lighting and 

comfortable temperatures.

 Routinely evaluate the program and make adjustments 

as needed.

Steps Retail Employers Can Take 

Right Away 

[NIOSH 1997, 2004 2012a, 2015c, 2017; Anderson and Chun 

2014; Galinsky et al. 2000; ACOEM 2012; Iridiastadi and 

Nussbaum 2006; Techera et al. 2016; Rahman et al. 2014; 

Mayo Clinic 2018; ODPHP 2015]

When making schedules, employers should determine necessary staffing level and not depend on fewer workers to work 

longer hours. Rotation schedules should allow for recovery 

from the night shift, and tasks and the work environment 

should be designed to maximize alertness and protect 

against errors. 

Employers should also consider following these specific strategies when developing schedules and assigning shifts:

 Allow for variation in work tasks, duties, and body position to avoid monotony and muscle fatigue (for more 

information about counteracting the effects of stationary 

positions, see NIOSH 2017].

 Allow for adequate rest breaks. Frequent brief breaks (e.g., 

every 1-2 hours) during demanding work are more effective against fatigue than a few long breaks. Allow longer 

breaks for meals. Rest breaks can be implemented without 

a resulting decrease in performance. (Naps during breaks 

could last 20-30 minutes. See NIOSH 2015c Part 2 Module 

7 for information about using naps).

 Allow at least 10 hours between shifts so employees can 

get 7-8 hours of sleep.

 Avoid using rotating shift schedules that change every 

week: for example, one week of day shift, one week of 

night shift (work hours include midnight to 6 A.M.). 

Most workers bodies have difficulty adjusting to weekly 

rotating schedules because of the way the human body is 

designed (human physiology). See NIOSH (2015c) Part 

2 Module 5 for information about designing appropriate 

work schedules.

 Limit night shifts to no longer than 8 hours whenever possible.

 Ensure that 12-hour shifts do not include excessive 

workloads.

 Plan one or two full days of rest to follow five consecutive 

8-hour shifts or four 10-hour shifts. Consider 2 rest days 

after 3 consecutive 12-hour shifts.

 Avoid scheduling an employee to work an opening shift 

right after a closing shift.

 Schedule strenuous work when employees are most alert.

 Give as much advanced notice as possible for schedule change.

 Record injury incidents and near misses and collect information about fatigue-related factors to determine whether 

fatigue contributed to the incident.

 Provide anti-fatigue mats, shoe inserts, and sit stand chairs/

stools for cashiers and others who stand for long periods.
5

 Design the work environment to minimize noise and 

vibration. Ensure adequate lighting and comfortable 

temperatures. 

 Provide the opportunity for healthful and balanced meals 

to help reduce stress and improve productivity:

— Share information with workers about current recommendations for healthful eating through fliers, 

internal websites, and posters.

— Provide healthful snacks during meetings and in 

vending machines and cafeterias.

— Provide refrigerators and microwaves at work so 

workers can bring healthful food from home.

Steps Employees Can Take 

Right Away 

Retail employees can consider the following strategies to 

reduce fatigue: 

 Make sure to give yourself enough time to sleep after 

working your shift.

 Sleep some place dark, comfortable, quiet, and cool so you 

can fall asleep quickly and stay asleep.

 Seek assistance from an appropriate healthcare provider if 

you are having difficulties sleeping.

 Get the 7 or more hours of sleep that you need each day to 

feel refreshed and alert.

 Follow current nutrition guidelines on healthful meals 

and snacks.

 Avoid heavy foods and alcohol before sleeping since these 

can make it difficult to get quality sleep.

 Exercise routinely, as keeping physically fit can help you 

manage stress, stay healthy, and improve your sleep.

 Drink enough water to replace fluids loss from the heat 

and workload; do not wait until you feel thirsty.

 More strategies for employees are available in Part 2, Modules 6 to 11 of NIOSH 2015c. 

Acknowledgments

This document was prepared by Susan Afanuh of the National 

Institute for Occupational Safety and Health, with input 

from the following NIOSH Programs: Total Worker Health®, 

Healthy Work Design and Well-Being, and Wholesale Retail 

Trade. Subject matter expert review was provided by Claire 

Caruso and Vern Anderson.

Suggested Citation

NIOSH [2018]. Using Total Worker Health® Concepts 

to Reduce Fatigue Among Retail Workers. By Afanuh 

S. Cincinnati, OH: U.S. Department of Health and 

Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and 

Health, DHHS (NIOSH) Publication No. 2019-102.

DOI: https://doi.org/10.26616/NIOSHPUB2019102

monkeybusinessimages/iStock/Getty Images Plus/Getty Images
6

References

ACOEM Presidential Task Force on Fatigue Risk Management [2012]. ACOEM guidance statement: fatigue risk 

management in the workplace. J Occup Environ Med 

54(2):231–258. http://www.acoem.org/uploadedFiles/

Public_Affairs/Policies_And_Position_Statements/

Fatigue%20Risk%20Management%20in%20the%20

Workplace.pdf

AHA (American Heart Association) [2014]. Staying hydrated 

—staying healthy. http://www.heart.org/HEARTORG/

HealthyLiving/PhysicalActivity/FitnessBasics/StayingHydrated---Staying-Healthy_UCM_441180_Article.jsp#.

WxAD68JlLL9

Anderson V, Chun H [2014]. Workplace hazards and prevention options from a nonrandom sample of retail trade 

businesses. Int J Occup Safety Ergonomics 20(1):181–195. 

ANSES [2016]. Assessment of the health risks for professionals exposed to atypical working hours, especially night 

work. Agence Nationale de Sécurité Sanitaire, Alimentation, Environnement, Travail. https://www.anses.fr/en/

system/files/AP2011SA0088RaEN.pdf

BLS [2005]. Shifts usually worked. Washington, DC: U.S. 

Department of Labor, Bureau of Labor Statistics. https://

www.bls.gov/news.release/flex.t05.htm

BLS [2015]. Table R4. Number of nonfatal occupational 

injuries and illnesses involving days away from work by 

industry and selected events or exposures leading to injury 

or illness, private industry, 2014. Washington, DC; U.S. 

Department of Labor, Bureau of Labor Statistics, https://

www.bls.gov/iif/oshwc/osh/case/ostb4370.pdf

BLS [2016]. Nonfatal occupational injuries and illnesses 

requiring days away from work, 2015. https://www.bls.gov/

news.release/osh2.nr0.htm

Caruso C [2014]. Negative impact of shift work and long 

work hours. Rehabil Nurs 39(1):16–25. https://www.ncbi.

nlm.nih.gov/pmc/articles/PMC4629843/

CDC [2012]. The National Healthy Worksite Program https://

www.cdc.gov/workplacehealthpromotion/pdf/nhwpprogram-overview.pdf

CDC [2014]. Workplace health promotion. http://www.cdc.

gov/workplacehealthpromotion/

Colten HR, Altevogt BM [2006]. Sleep disorders and sleep 

deprivation: an unmet public health problem. Washington, 

D.C.: National Academies. https://www.ncbi.nlm.nih.gov/

books/NBK19960/pdf/Bookshelf_NBK19960.pdf

DOL [n.d.]. YouthRules! Washington, DC: U.S. Department 

of Labor. https://www.youthrules.gov/

Fabius R, Thayer R, Dixon BA, Konicki DL, Yarborough CM, 

Peterson KW, Isaac F, Loeppke RR, Eisenberg BS, Dreger M 

[2013]. The link between workforce health and safety and 

the health of the bottom line: tracking market performance 

of companies that nurture a “culture of health.” J Occup 

Environ Med 55(9):993–1000.

Galinsky TL, Swanson NG, Sauter SL, Hurrell JJ, Schleifer 

LM [2000]. A field study of supplementary rest breaks for 

data-entry operators. Ergonomics 43(5):622–638.

Goetzel RZ, Ozminkowski RJ [2008]. The health and cost 

benefits of work site health-promotion programs.

Ann Rev Public Health 29:303–323. http://www.

annualreviews.org/doi/full/10.1146/annurev.publ

health.29.020907.090930?url_ver=Z39.88-2003&rfr_

id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed

Goetzel RZ, Henke RM, Tabrizi M, Pelletier KR, Loeppke 

R, Ballard DW, Grossmeier J, Anderson DR, Yach D, Kelly 

RK, McCalister T, Serxner S, Selecky C, Shallenberger LG, 

Fries JF, Baase C, Isaac F, Crighton KA, Wald P, Exum E, 

Shurney D, Metz RD [2014]. Do workplace health promotion (wellness) programs work? Am College Occup Environ 

Med 56(9):927–934.

Greenhouse S [2015]. In service sector, no rest for the working. New York Times, February 22, https://www.nytimes.

com/2015/02/22/business/late-to-bed-early-to-rise-andworking-tired.html?_r=0

Harvard School of Public Health [2016]. The workplace and 

health. NPR/Robert Wood Johnson Foundation/Harvard 

School of Public Health. http://www.rwjf.org/content/dam/

farm/reports/surveys_and_polls/2016/rwjf430330

Iridiastadi H, Nussbaum MA [2006]. Muscle fatigue 

and endurance during repetitive intermittent static 

efforts: development of prediction models. Ergonomics 

49(4):344–360.

Katz LF, Krueger AB [2016]. The rise and nature of alternative work arrangements in the United States, 1995-2015. 

Harvard University and NBER; Princeton University and 

NBER. https://krueger.princeton.edu/sites/default/files/

akrueger/files/katz_krueger_cws_-_march_29_20165.pdf

Lambert SJ, Fugiel PJ, Henly HR [2014]. Schedule unpredictability among early career workers in the US labor market: 

a national snapshot (executive summary). University of 

Chicago. https://ssascholars.uchicago.edu/sites/default/

files/einet/files/lambert.fugiel.henly_.executive_

summary.b_0.pdf

Mukherjee S, Patel SR, Kales SN, Ayas NT, Strohl KP, Gozal 

D, Malhotra A [2015]. An official American Thoracic 

Society statement: the importance of healthy sleep. Recommendations and future priorities. Am J Respir Crit Care 

Med 191(12):1450–8.

Mayo Clinic [2018]. Dehydration. https://www.mayoclinic.

org/diseases-conditions/dehydration/symptoms-causes/

syc-20354086

National Sleep Foundation [2015]. 2015 Sleep in America® 

poll. Sleep and pain. http://www.sleephealthjournal.org/pb/

assets/raw/Health%20Advance/journals/sleh/2015SleepinA

mericaPollSummaryofFindings.pdf

NIOSH [1997]. Plain language about shift work. By Rosa 

RR, Colligan MJ. DHHS (NIOSH) Publication No. 97-141. 

https://www.cdc.gov/niosh/docs/97-145/pdfs/97-145.pdf
7

NIOSH [2002]. The changing organization of work and the 

safety and health of working people. By The NORA Organization of Work Team. Cincinnati, OH: U.S. Department 

of Health and Human Services, Centers for Disease Control 

and Prevention, National Institute for Occupational Safety 

and Health, DHHS (NIOSH) Publication No. 2002-116. 

https://www.cdc.gov/niosh/docs/2002-116/

NIOSH [2004]. Overtime and extended work shifts: recent 

findings on illnesses, injuries, and health behaviors. By 

Caruso CC, Hitchcock EM, Dick RB, Russo JM, Schmit JM. 

Cincinnati, OH: U.S. Department of Health and Human 

Services, Centers for Disease Control and Prevention, 

National Institute for Occupational Safety and Health, 

DHHS (NIOSH) Publication No. 2004-143. https://www.

cdc.gov/niosh/docs/2004-143/default.html

NIOSH [2012a]. NIOSH Science Blog: sleep and 

work. By Caruso C, Rosa R. https://blogs.cdc.gov/

niosh-science-blog/2012/03/08/sleep-and-work/

NIOSH [2012b]. Preventing slips, trips, and falls in wholesale 

and retail trade establishments. By Anderson V, Afanuh S, 

and Bell J. Cincinnati, OH: U.S. Department of Health and 

Human Services, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, 

DHHS (NIOSH) Publication No. 2013-100. https://www.

cdc.gov/niosh/docs/2013-100/

NIOSH [2014] Total Worker Health Infographic: top reasons to create a new pathway for a safer and healthier 

workforce. http://www.cdc.gov/niosh/twh/topreasons/

infographic.html

NIOSH [2015a]. National health interview survey: occupational health supplement. https://www.cdc.gov/niosh/

topics/nhis/

NIOSH [2015b]. NIOSH Workplace Safety and Health Topic: 

Total Worker Health. https://www.cdc.gov/niosh/twh/

totalhealth.html

NIOSH [2015c]. NIOSH training for nurses on shift work and 

long work hours. By Caruso CC, Geiger-Brown J, Takahashi 

M, Trinkoff A, Nakata A. Cincinnati, OH: U.S. Department 

of Health and Human Services, Centers for Disease Control 

and Prevention, National Institute for Occupational Safety 

and Health, DHHS (NIOSH) Publication No. 2015-115. 

https://www.cdc.gov/niosh/docs/2015-115/default.html

NIOSH [2017]. Using Total Worker Health® concepts to 

reduce the health risks from sedentary work. DHHS 

(NIOSH) Publication No. 2017-131. https://www.cdc.gov/

niosh/docs/wp-solutions/2017-131/

NIOSH [2018]. Wholesale and retail trade. https://www.cdc.

gov/niosh/about/strategicplan/musctrade.html

NORA Sector Council [2016]. Sleep deficiency, fatigue, 

pain, and loss of productivity in retail work. NORA Sector 

Council Bulletin: Wholesale and Retail Trade. Issue 7, July. 

https://www.cdc.gov/niosh/programs/wrt/pdfs/wrt-sectorcouncil-bulletinw3-2016-07-20.pdf

ODPHP [2015]. Dietary guidelines for Americans, 2015–

2020. https://health.gov/dietaryguidelines/2015/guidelines/

OHSU [2018]. Health impacts safety. Portland, OR: Oregon 

Institute of Occupational Health Sciences. https://www.

ohsu.edu/xd/research/centers-institutes/oregon-instituteoccupational-health-sciences/outreach/impact.cfm

OPM [n.d.]. Work-life. Washington, DC: Office of Personnel 

Management. https://www.opm.gov/policy-data-oversight/

worklife/employee-assistance-programs/

OSHA [n.d.]. Long work hours, extended or irregular shifts, 

and worker fatigue. Washington, DC: U.S. Department of 

Labor, Occupational Safety and Health Administration. 

https://www.osha.gov/SLTC/workerfatigue/index.html

Rahman SA, Flynn-Evans EE, Aeschbach D, Brainard GC, 

Czeisler CA, Lockley SW [2014]. Diurnal spectral sensitivity of the acute alerting effects of light. Sleep 37(2):271–281.

Schulte PA, Wagner GW, Ostry A, Blanciforti LA, Cutlip RG, 

Krajnak KM, Luster M, Munson AE, O’Callaghan JP, Parks 

CG, Simeonova PP, Miller DB [2007]. Work, obesity, and 

occupational safety and health. Am J Public Health 97(3): 

428–436. http://www.ncbi.nlm.nih.gov/pmc/articles/

PMC1805035/

Schulte PA, Pandalai S, Wulsin V, Chun H [2012]. Interaction of occupational and personal risk factors inworkforce 

health and safety. Am J Public Health 102(3):434–448 

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3487655/

Schulte PA, Schill AL, Guerin RJ, Bhattacharya A, Cunningham TR, Pandalai SP, Eggerth D, Stephenson CM [2015]. 

Considerations for incorporating “well-being” in public 

policy for workers and workplaces. Am J Public Health 

105(8):e31–e44. https://www.ncbi.nlm.nih.gov/pmc/

articles/PMC4504308/

Sorenson G, McLellan D, Dennerlein JT, Pronk NP, Allen 

JD, Boden LI, Okechukwu CA, Hashimoto D, Stoddard 

A, Wagner GR [2013]. Integration of health protection 

and health promotion: rationale, indicators, and metrics. J 

Occup Med 55(120)S12–S18. http://www.ncbi.nlm.nih.gov/

pmc/articles/PMC4184212/

Techera U, Hallowell M, Stambaugh N, Littlejohn R [2016]. 

Cases and consequences of occupational fatigue: metaanalysis and systems model. J Occup Environ Med August. 

https://www.ncbi.nlm.nih.gov/pubmed/27525527
For More Information

More information is available on the NIOSH website about the 

following programs and research:

Total Worker Health® 

https://www.cdc.gov/niosh/twh/letsgetstarted.html

Work schedules: shift work and long hours

https://www.cdc.gov/niosh/topics/workschedules/

Wholesale and Retail Trade 

https://www.cdc.gov/niosh/programs/wrt/

Healthy work design and well-being program

https://www.cdc.gov/niosh/programs/hwd/default.html

To receive documents or other information about occupational 

safety and health topics, contact NIOSH at

Phone: 1-800-CDC-INFO (1-800-232-4636)

TTY: 1-888-232-6348

Email: cdcinfo@cdc.gov

or visit the NIOSH website at www.cdc.gov/niosh

For a monthly update on news at NIOSH, subscribe to NIOSH 

eNews by visiting www.cdc.gov/niosh/eNews

Mention of any company or product does not constitute 

endorsement by the National Institute for Occupational 

Safety and Health (NIOSH), Centers for Disease Control 

and Prevention (CDC). In addition, citations to websites 

external to NIOSH do not constitute NIOSH endorsement 

of the sponsoring organizations or their programs or 

products. Furthermore, NIOSH is not responsible for the 

content of these websites. All web addresses referenced in 

this document were accessible as of the publication date.

This document is in the public domain and may be freely 

copied or reprinted. NIOSH encourages all readers of 

the Workplace Solutions to make them available to all 

interested employers and workers.

As part of the Centers for Disease Control and Prevention, 

NIOSH is the Federal agency responsible for conducting 

research and making recommendations to prevent workrelated illnesses and injuries. All Workplace Solutions are based 

on research studies that show how worker exposures to hazardous agents or activities can be significantly reduced.

DHHS (NIOSH) Publication No. 2019-102

DOI: https://doi.org/10.26616/NIOSHPUB2019102

November 2018