health education case study

Health Case Studies

(29 reviews)

Glynda Rees, British Columbia Institute of Technology

Rob Kruger, British Columbia Institute of Technology

Janet Morrison, British Columbia Institute of Technology

Publisher: BCcampus

Language: English

Formats Available

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Reviewed by Jessica Sellars, Medical assistant office instructor, Blue Mountain Community College on 10/11/23

Comprehensiveness rating: 5 see less

This is a book of compiled and very well organized patient case studies. The author has broken it up by disease patient was experiencing and even the healthcare roles that took place in this patients care. There is a well thought out direction and plan. There is an appendix to refer to as well if you are needing to find something specific quickly. I have been looking for something like this to help my students have a base to do their project on. This is the most comprehensive version I have found on the subject.

Content Accuracy rating: 5

This is a book compiled of medical case studies. It is very accurate and can be used to learn from great care and mistakes.

Relevance/Longevity rating: 5

This material is very relevant in this context. It also has plenty of individual case studies to utilize in many ways in all sorts of medical courses. This is a very useful textbook and it will continue to be useful for a very long time as you can still learn from each study even if medicine changes through out the years.

Clarity rating: 5

The author put a lot of thought into the ease of accessibility and reading level of the target audience. There is even a "how to use this resource" section which could be extremely useful to students.

Consistency rating: 5

The text follows a very consistent format throughout the book.

Modularity rating: 5

Each case study is individual broken up and in a group of similar case studies. This makes it extremely easy to utilize.

Organization/Structure/Flow rating: 5

The book is very organized and the appendix is through. It flows seamlessly through each case study.

Interface rating: 5

I had no issues navigating this book, It was clearly labeled and very easy to move around in.

Grammatical Errors rating: 5

I did not catch any grammar errors as I was going through the book

Cultural Relevance rating: 5

This is a challenging question for any medical textbook. It is very culturally relevant to those in medical or medical office degrees.

I have been looking for something like this for years. I am so happy to have finally found it.

Reviewed by Cindy Sun, Assistant Professor, Marshall University on 1/7/23

Interestingly, this is not a case of ‘you get what you pay for’. Instead, not only are the case studies organized in a fashion for ease of use through a detailed table of contents, the authors have included more support for both faculty and students. For faculty, the introduction section titled ‘How to use this resource’ and individual notes to educators before each case study contain application tips. An appendix overview lists key elements as issues / concepts, scenario context, and healthcare roles for each case study. For students, learning objectives are presented at the beginning of each case study to provide a framework of expectations.

The content is presented accurately and realistic.

The case studies read similar to ‘A Day In the Life of…’ with detailed intraprofessional communications similar to what would be overheard in patient care areas. The authors present not only the view of the patient care nurse, but also weave interprofessional vantage points through each case study by including patient interaction with individual professionals such as radiology, physician, etc.

In addition to objective assessment findings, the authors integrate standard orders for each diagnosis including medications, treatments, and tests allowing the student to incorporate pathophysiology components to their assessments.

Each case study is arranged in the same framework for consistency and ease of use.

This compilation of eight healthcare case studies focusing on new onset and exacerbation of prevalent diagnoses, such as heart failure, deep vein thrombosis, cancer, and chronic obstructive pulmonary disease advancing to pneumonia.

Each case study has a photo of the ‘patient’. Simple as this may seem, it gives an immediate mental image for the student to focus.

Interface rating: 4

As noted by previous reviewers, most of the links do not connect active web pages. This may be due to the multiple options for accessing this resource (pdf download, pdf electronic, web view, etc.).

Grammatical Errors rating: 4

A minor weakness that faculty will probably need to address prior to use is regarding specific term usages differences between Commonwealth countries and United States, such as lung sound descriptors as ‘quiet’ in place of ‘diminished’ and ‘puffers’ in place of ‘inhalers’.

The authors have provided a multicultural, multigenerational approach in selection of patient characteristics representing a snapshot of today’s patient population. Additionally, one case study focusing on heart failure is about a middle-aged adult, contrasting to the average aged patient the students would normally see during clinical rotations. This option provides opportunities for students to expand their knowledge on risk factors extending beyond age.

This resource is applicable to nursing students learning to care for patients with the specific disease processes presented in each case study or for the leadership students focusing on intraprofessional communication. Educators can assign as a supplement to clinical experiences or as an in-class application of knowledge.

Reviewed by Stephanie Sideras, Assistant Professor, University of Portland on 8/15/22

The eight case studies included in this text addressed high frequency health alterations that all nurses need to be able to manage competently. While diabetes was not highlighted directly, it was included as a potential comorbidity. The five overarching learning objectives pulled from the Institute of Medicine core competencies will clearly resonate with any faculty familiar with Quality and Safety Education for Nurses curriculum.

The presentation of symptoms, treatments and management of the health alterations was accurate. Dialogue between the the interprofessional team was realistic. At times the formatting of lab results was confusing as they reflected reference ranges specific to the Canadian healthcare system but these occurrences were minimal and could be easily adapted.

The focus for learning from these case studies was communication - patient centered communication and interprofessional team communication. Specific details, such as drug dosing, was minimized, which increases longevity and allows for easy individualization of the case data.

While some vocabulary was specific to the Canadian healthcare system, overall the narrative was extremely engaging and easy to follow. Subjective case data from patient or provider were formatted in italics and identified as 'thoughts'. Objective and behavioral case data were smoothly integrated into the narrative.

The consistency of formatting across the eight cases was remarkable. Specific learning objectives are identified for each case and these remain consistent across the range of cases, varying only in the focus for the goals for each different health alterations. Each case begins with presentation of essential patient background and the progress across the trajectory of illness as the patient moves from location to location encountering different healthcare professionals. Many of the characters (the triage nurse in the Emergency Department, the phlebotomist) are consistent across the case situations. These consistencies facilitate both application of a variety of teaching methods and student engagement with the situated learning approach.

Case data is presented by location and begins with the patient's first encounter with the healthcare system. This allows for an examination of how specific trajectories of illness are manifested and how care management needs to be prioritized at different stages. This approach supports discussions of care transitions and the complexity of the associated interprofessional communication.

The text is well organized. The case that has two levels of complexity is clearly identified

The internal links between the table of contents and case specific locations work consistently. In the EPUB and the Digital PDF the external hyperlinks are inconsistently valid.

The grammatical errors were minimal and did not detract from readability

Cultural diversity is present across the cases in factors including race, ethnicity, socioeconomic status, family dynamics and sexual orientation.

The level of detail included in these cases supports a teaching approach to address all three spectrums of learning - knowledge, skills and attitudes - necessary for the development of competent practice. I also appreciate the inclusion of specific assessment instruments that would facilitate a discussion of evidence based practice. I will enjoy using these case to promote clinical reasoning discussions of data that is noticed and interpreted with the resulting prioritizes that are set followed by reflections that result from learner choices.

Reviewed by Chris Roman, Associate Professor, Butler University on 5/19/22

It would be extremely difficult for a book of clinical cases to comprehensively cover all of medicine, and this text does not try. Rather, it provides cases related to common medical problems and introduces them in a way that allows for various... read more

Comprehensiveness rating: 4 see less

The narrative form of the cases is less subject to issues of accuracy than a more content-based book would be. That said, the cases are realistic and reasonable, avoiding being too mundane or too extreme.

These cases are narrative and do not include many specific mentions of drugs, dosages, or other aspects of clinical care that may grow/evolve as guidelines change. For this reason, the cases should be “evergreen” and can be modified to suit different types of learners.

Clarity rating: 4

The text is written in very accessible language and avoids heavy use of technical language. Depending on the level of learner, this might even be too simplistic and omit some details that would be needed for physicians, pharmacists, and others to make nuanced care decisions.

The format is very consistent with clear labeling at transition points.

The authors point out in the introductory materials that this text is designed to be used in a modular fashion. Further, they have built in opportunities to customize each cases, such as giving dates of birth at “19xx” to allow for adjustments based on instructional objectives, etc.

The organization is very easy to follow.

I did not identify any issues in navigating the text.

The text contains no grammatical errors, though the language is a little stiff/unrealistic in some cases.

Cases involve patients and members of the care team that are of varying ages, genders, and racial/ethnic backgrounds

Reviewed by Trina Larery, Assistant Professor, Pittsburg State University on 4/5/22

The book covers common scenarios, providing allied health students insight into common health issues. The information in the book is thorough and easily modified if needed to include other scenarios not listed. The material was easy to understand... read more

Content Accuracy rating: 4

The treatments were explained and rationales were given, which can be very helpful to facilitate effective learning for a nursing student or novice nurse. The case studies were accurate in explanation. The DVT case study incorrectly identifies the location of the clot in the popliteal artery instead of in the vein.

The content is relevant to a variety of different types of health care providers and due to the general nature of the cases, will remain relevant over time. Updates should be made annually to the hyperlinks and to assure current standard of practice is still being met.

Clear, simple and easy to read.

Consistent with healthcare terminology and framework throughout all eight case studies.

The text is modular. Cases can be used individually within a unit on the given disease process or relevant sections of a case could be used to illustrate a specific point providing great flexibility. The appendix is helpful in locating content specific to a certain diagnosis or a certain type of health care provider.

The book is well organized, presenting in a logical clear fashion. The appendix allows the student to move about the case study without difficulty.

The interface is easy and simple to navigate. Some links to external sources might need to be updated regularly since those links are subject to change based on current guidelines. A few hyperlinks had "page not found".

Few grammatical errors were noted in text.

The case studies include people of different ethnicities, socioeconomic status, ages, and genders to make this a very useful book.

I enjoyed reading the text. It was interesting and relevant to today's nursing student. There are roughly 25 broken online links or "pages not found", care needs to be taken to update at least annually and assure links are valid and utilizing the most up to date information.

Reviewed by Benjamin Silverberg, Associate Professor/Clinician, West Virginia University on 3/24/22

Comprehensiveness rating: 3 see less

The appendix reviews the "key roles" and medical venues found in all 8 cases, but is fairly spartan on medical content. The table of contents at the beginning only lists the cases and locations of care. It can be a little tricky to figure out what is going on where, especially since each case is largely conversation-based. Since this presents 8 cases (really 7 with one being expanded upon), there are many medical topics (and venues) that are not included. It's impossible to include every kind of situation, but I'd love to see inclusion of sexual health, renal pathology, substance abuse, etc.

Though there are differences in how care can be delivered based on personal style, changing guidelines, available supplies, etc, the medical accuracy seems to be high. I did not detect bias or industry influence.

Relevance/Longevity rating: 4

Medications are generally listed as generics, with at least current dosing recommendations. The text gives a picture of what care looks like currently, but will be a little challenging to update based on new guidelines (ie, it can be hard to find the exact page in which a medication is dosed/prescribed). Even if the text were to be a little out of date, an instructor can use that to point out what has changed (and why).

Clear text, usually with definitions of medical slang or higher-tier vocabulary. Minimal jargon and there are instances where the "characters" are sorting out the meaning as well, making it accessible for new learners, too.

Overall, the style is consistent between cases - largely broken up into scenes and driven by conversation rather than descriptions of what is happening.

There are 8 (well, again, 7) cases which can be reviewed in any order. Case #2 builds upon #1, which is intentional and a good idea, though personally I would have preferred one case to have different possible outcomes or even a recurrence of illness. Each scene within a case is reasonably short.

Organization/Structure/Flow rating: 4

These cases are modular and don't really build on concepts throughout. As previously stated, case #2 builds upon #1, but beyond that, there is no progression. (To be sure, the authors suggest using case #1 for newer learners and #2 for more advanced ones.) The text would benefit from thematic grouping, a longer introduction and debriefing for each case (there are learning objectives but no real context in medical education nor questions to reflect on what was just read), and progressively-increasing difficulty in medical complexity, ethics, etc.

I used the PDF version and had no interface issues. There are minimal photographs and charts. Some words are marked in blue but those did not seem to be hyperlinked anywhere.

No noticeable errors in grammar, spelling, or formatting were noted.

I appreciate that some diversity of age and ethnicity were offered, but this could be improved. There were Canadian Indian and First Nations patients, for example, as well as other characters with implied diversity, but there didn't seem to be any mention of gender diverse or non-heterosexual people, or disabilities. The cases tried to paint family scenes (the first patient's dog was fairly prominently mentioned) to humanize them. Including more cases would allow for more opportunities to include sex/gender minorities, (hidden) disabilities, etc.

The text (originally from 2017) could use an update. It could be used in conjunction with other Open Texts, as a compliment to other coursework, or purely by itself. The focus is meant to be on improving communication, but there are only 3 short pages at the beginning of the text considering those issues (which are really just learning objectives). In addition to adding more cases and further diversity, I personally would love to see more discussion before and after the case to guide readers (and/or instructors). I also wonder if some of the ambiguity could be improved by suggesting possible health outcomes - this kind of counterfactual comparison isn't possible in real life and could be really interesting in a text. Addition of comprehension/discussion questions would also be worthwhile.

Reviewed by Danielle Peterson, Assistant Professor, University of Saint Francis on 12/31/21

This text provides readers with 8 case studies which include both chronic and acute healthcare issues. Although not comprehensive in regard to types of healthcare conditions, it provides a thorough look at the communication between healthcare workers in acute hospital settings. The cases are primarily set in the inpatient hospital setting, so the bulk of the clinical information is basic emergency care and inpatient protocol: vitals, breathing, medication management, etc. The text provides a table of contents at opening of the text and a handy appendix at the conclusion of the text that outlines each case’s issue(s), scenario, and healthcare roles. No index or glossary present.

Although easy to update, it should be noted that the cases are taking place in a Canadian healthcare system. Terms may be unfamiliar to some students including “province,” “operating theatre,” “physio/physiotherapy,” and “porter.” Units of measurement used include Celsius and meters. Also, the issue of managed care, health insurance coverage, and length of stay is missing for American students. These are primary issues that dictate much of the healthcare system in the US and a primary job function of social workers, nurse case managers, and medical professionals in general. However, instructors that wish to add this to the case studies could do so easily.

The focus of this text is on healthcare communication which makes it less likely to become obsolete. Much of the clinical information is stable healthcare practice that has been standard of care for quite some time. Nevertheless, given the nature of text, updates would be easy to make. Hyperlinks should be updated to the most relevant and trustworthy sources and checked frequently for effectiveness.

The spacing that was used to note change of speaker made for ease of reading. Although unembellished and plain, I expect students to find this format easy to digest and interesting, especially since the script is appropriately balanced with ‘human’ qualities like the current TV shows and songs, the use of humor, and nonverbal cues.

A welcome characteristic of this text is its consistency. Each case is presented in a similar fashion and the roles of the healthcare team are ‘played’ by the same character in each of the scenarios. This allows students to see how healthcare providers prioritize cases and juggle the needs of multiple patients at once. Across scenarios, there was inconsistency in when clinical terms were hyperlinked.

The text is easily divisible into smaller reading sections. However, since the nature of the text is script-narrative format, if significant reorganization occurs, one will need to make sure that the communication of the script still makes sense.

The text is straightforward and presented in a consistent fashion: learning objectives, case history, a script of what happened before the patient enters the healthcare setting, and a script of what happens once the patient arrives at the healthcare setting. The authors use the term, “ideal interactions,” and I would agree that these cases are in large part, ‘best case scenarios.’ Due to this, the case studies are well organized, clear, logical, and predictable. However, depending on the level of student, instructors may want to introduce complications that are typical in the hospital setting.

The interface is pleasing and straightforward. With exception to the case summary and learning objectives, the cases are in narrative, script format. Each case study supplies a photo of the ‘patient’ and one of the case studies includes a link to a 3-minute video that introduces the reader to the patient/case. One of the highlights of this text is the use of hyperlinks to various clinical practices (ABG, vital signs, transfer of patient). Unfortunately, a majority of the links are broken. However, since this is an open text, instructors can update the links to their preference.

Although not free from grammatical errors, those that were noticed were minimal and did not detract from reading.

Cultural Relevance rating: 4

Cultural diversity is visible throughout the patients used in the case studies and includes factors such as age, race, socioeconomic status, family dynamics, and sexual orientation. A moderate level of diversity is noted in the healthcare team with some stereotypes: social workers being female, doctors primarily male.

As a social work instructor, I was grateful to find a text that incorporates this important healthcare role. I would have liked to have seen more content related to advance directives, mediating decision making between the patient and care team, emotional and practical support related to initial diagnosis and discharge planning, and provision of support to colleagues, all typical roles of a medical social worker. I also found it interesting that even though social work was included in multiple scenarios, the role was only introduced on the learning objectives page for the oncology case.

Reviewed by Crystal Wynn, Associate Professor, Virginia State University on 7/21/21

The text covers a variety of chronic diseases within the cases; however, not all of the common disease states were included within the text. More chronic diseases need to be included such as diabetes, cancer, and renal failure. Not all allied health care team members are represented within the case study. Key terms appear throughout the case study textbook and readers are able to click on a hyperlink which directs them to the definition and an explanation of the key term.

Content is accurate, error-free and unbiased.

The content is up-to-date, but not in a way that will quickly make the text obsolete within a short period of time. The text is written and/or arranged in such a way that necessary updates will be relatively easy and straightforward to implement.

The text is written in lucid, accessible prose, and provides adequate context for any jargon/technical terminology used

The text is internally consistent in terms of terminology and framework.

The text is easily and readily divisible into smaller reading sections that can be assigned at different points within the course. Each case can be divided into a chronic disease state unit, which will allow the reader to focus on one section at a time.

Organization/Structure/Flow rating: 3

The topics in the text are presented in a logical manner. Each case provides an excessive amount of language that provides a description of the case. The cases in this text reads more like a novel versus a clinical textbook. The learning objectives listed within each case should be in the form of questions or activities that could be provided as resources for instructors and teachers.

Interface rating: 3

There are several hyperlinks embedded within the textbook that are not functional.

The text contains no grammatical errors.

Cultural Relevance rating: 3

The text is not culturally insensitive or offensive in any way. More examples of cultural inclusiveness is needed throughout the textbook. The cases should be indicative of individuals from a variety of races and ethnicities.

Reviewed by Rebecca Hillary, Biology Instructor, Portland Community College on 6/15/21

This textbook consists of a collection of clinical case studies that can be applicable to a wide range of learning environments from supplementing an undergraduate Anatomy and Physiology Course, to including as part of a Medical or other health care program. I read the textbook in E-reader format and this includes hyperlinks that bring the students to subsequent clinical study if the book is being used in a clinical classroom. This book is significantly more comprehensive in its approach from other case studies I have read because it provides a bird’s eye view of the many clinicians, technicians, and hospital staff working with one patient. The book also provides real time measurements for patients that change as they travel throughout the hospital until time of discharge.

Each case gave an accurate sense of the chaos that would be present in an emergency situation and show how the conditions affect the practitioners as well as the patients. The reader gets an accurate big picture--a feel for each practitioner’s point of view as well as the point of view of the patient and the patient’s family as the clock ticks down and the patients are subjected to a number of procedures. The clinical information contained in this textbook is all in hyperlinks containing references to clinical skills open text sources or medical websites. I did find one broken link on an external medical resource.

The diseases presented are relevant and will remain so. Some of the links are directly related to the Canadian Medical system so they may not be applicable to those living in other regions. Clinical links may change over time but the text itself will remain relevant.

Each case study clearly presents clinical data as is it recorded in real time.

Each case study provides the point of view of several practitioners and the patient over several days. While each of the case studies covers different pathology they all follow this same format, several points of view and data points, over a number of days.

The case studies are divided by days and this was easy to navigate as a reader. It would be easy to assign one case study per body system in an Anatomy and Physiology course, or to divide them up into small segments for small in class teaching moments.

The topics are presented in an organized way showing clinical data over time and each case presents a large number of view points. For example, in the first case study, the patient is experiencing difficulty breathing. We follow her through several days from her entrance to the emergency room. We meet her X Ray Technicians, Doctor, Nurses, Medical Assistant, Porter, Physiotherapist, Respiratory therapist, and the Lab Technicians running her tests during her stay. Each practitioner paints the overall clinical picture to the reader.

I found the text easy to navigate. There were not any figures included in the text, only clinical data organized in charts. The figures were all accessible via hyperlink. Some figures within the textbook illustrating patient scans could have been helpful but I did not have trouble navigating the links to visualize the scans.

I did not see any grammatical errors in the text.

The patients in the text are a variety of ages and have a variety of family arrangements but there is not much diversity among the patients. Our seven patients in the eight case studies are mostly white and all cis gendered.

Some of the case studies, for example the heart failure study, show clinical data before and after drug treatments so the students can get a feel for mechanism in physiological action. I also liked that the case studies included diet and lifestyle advice for the patients rather than solely emphasizing these pharmacological interventions. Overall, I enjoyed reading through these case studies and I plan to utilize them in my Anatomy and Physiology courses.

Reviewed by Richard Tarpey, Assistant Professor, Middle Tennessee State University on 5/11/21

As a case study book, there is no index or glossary. However, medical and technical terms provide a useful link to definitions and explanations that will prove useful to students unfamiliar with the terms. The information provided is appropriate for entry-level health care students. The book includes important health problems, but I would like to see coverage of at least one more chronic/lifestyle issue such as diabetes. The book covers adult issues only.

Content is accurate without bias

The content of the book is relevant and up-to-date. It addresses conditions that are prevalent in today's population among adults. There are no pediatric cases, but this does not significantly detract from the usefulness of the text. The format of the book lends to easy updating of data or information.

The book is written with clarity and is easy to read. The writing style is accessible and technical terminology is explained with links to more information.

Consistency is present. Lack of consistency is typically a problem with case study texts, but this book is consistent with presentation, format, and terminology throughout each of the eight cases.

The book has high modularity. Each of the case studies can be used independently from the others providing flexibility. Additionally, each case study can be partitioned for specific learning objectives based on the learning objectives of the course or module.

The book is well organized, presenting students conceptually with differing patient flow patterns through a hospital. The patient information provided at the beginning of each case is a wonderful mechanism for providing personal context for the students as they consider the issues. Many case studies focus on the problem and the organization without students getting a patient's perspective. The patient perspective is well represented in these cases.

The navigation through the cases is good. There are some terminology and procedure hyperlinks within the cases that do not work when accessed. This is troubling if you intend to use the text for entry-level health care students since many of these links are critical for a full understanding of the case.

There are some non-US variants of spelling and a few grammatical errors, but these do not detract from the content of the messages of each case.

The book is inclusive of differing backgrounds and perspectives. No insensitive or offensive references were found.

I like this text for its application flexibility. The book is useful for non-clinical healthcare management students to introduce various healthcare-related concepts and terminology. The content is also helpful for the identification of healthcare administration managerial issues for students to consider. The book has many applications.

Reviewed by Paula Baldwin, Associate Professor/Communication Studies, Western Oregon University on 5/10/21

The different case studies fall on a range, from crisis care to chronic illness care. read more

The different case studies fall on a range, from crisis care to chronic illness care.

The contents seems to be written as they occurred to represent the most complete picture of each medical event's occurence.

These case studies are from the Canadian medical system, but that does not interfere with it's applicability.

It is written for a medical audience, so the terminology is mostly formal and technical.

Some cases are shorter than others and some go in more depth, but it is not problematic.

The eight separate case studies is the perfect size for a class in the quarter system. You could combine this with other texts, videos or learning modalities, or use it alone.

As this is a case studies book, there is not a need for a logical progression in presentation of topics.

No problems in terms of interface.

I have not seen any grammatical errors.

I did not see anything that was culturally insensitive.

I used this in a Health Communication class and it has been extraordinarily successful. My studies are analyzing the messaging for the good, the bad, and the questionable. The case studies are widely varied and it gives the class insights into hospital experiences, both front and back stage, that they would not normally be able to examine. I believe that because it is based real-life medical incidents, my students are finding the material highly engaging.

Reviewed by Marlena Isaac, Instructor, Aiken Technical College on 4/23/21

This text is great to walk through patient care with entry level healthcare students. The students are able to take in the information, digest it, then provide suggestions to how they would facilitate patient healing. Then when they are faced with... read more

The case studies provided accurate information that relates to the named disease.

It is relevant to health care studies and the development of critical thinking.

Cases are straightforward with great clinical information.

Clinical information is provided concisely.

Appropriate for clinical case study.

Presented to facilitate information gathering.

Takes a while to navigate in the browser.

Cultural Relevance rating: 1

Text lacks adequate representation of minorities.

Reviewed by Kim Garcia, Lecturer III, University of Texas Rio Grande Valley on 11/16/20

The book has 8 case studies, so obviously does not cover the whole of medicine, but the cases provided are descriptive and well developed. Cases are presented at different levels of difficulty, making the cases appropriate for students at different levels of clinical knowledge. The human element of both patient and health care provider is well captured. The cases are presented with a focus on interprofessional interaction and collaboration, more so than teaching medical content.

Content is accurate and un-biased. No errors noted. Most diagnostic and treatment information is general so it will remain relevant over time. The content of these cases is more appropriate for teaching interprofessional collaboration and less so for teaching the medical care for each diagnosis.

The content is relevant to a variety of different types of health care providers (nurses, radiologic technicians, medical laboratory personnel, etc) and due to the general nature of the cases, will remain relevant over time.

Easy to read. Clear headings are provided for sections of each case study and these section headings clearly tell when time has passed or setting has changed. Enough description is provided to help set the scene for each part of the case. Much of the text is written in the form of dialogue involving patient, family and health care providers, making it easy to adapt for role play. Medical jargon is limited and links for medical terms are provided to other resources that expound on medical terms used.

The text is consistent in structure of each case. Learning objectives are provided. Cases generally start with the patient at home and move with the patient through admission, testing and treatment, using a variety of healthcare services and encountering a variety of personnel.

The text is modular. Cases could be used individually within a unit on the given disease process or relevant sections of a case could be used to illustrate a specific point. The appendix is helpful in locating content specific to a certain diagnosis or a certain type of health care provider.

Each case follows a patient in a logical, chronologic fashion. A clear table of contents and appendix are provided which allows the user to quickly locate desired content. It would be helpful if the items in the table of contents and appendix were linked to the corresponding section of the text.

The hyperlinks to content outside this book work, however using the back arrow on your browser returns you to the front page of the book instead of to the point at which you left the text. I would prefer it if the hyperlinks opened in a new window or tab so closing that window or tab would leave you back where you left the text.

No grammatical errors were noted.

The text is culturally inclusive and appropriate. Characters, both patients and care givers are of a variety of races, ethnicities, ages and backgrounds.

I enjoyed reading the cases and reviewing this text. I can think of several ways in which I will use this content.

Reviewed by Raihan Khan, Instructor/Assistant Professor, James Madison University on 11/3/20

The book contains several important health issues, however still missing some chronic health issues that the students should learn before they join the workforce, such as diabetes-related health issues suffered by the patients. read more

The health information contained in the textbook is mostly accurate.

I think the book is written focusing on the current culture and health issues faced by the patients. To keep the book relevant in the future, the contexts especially the culture/lifestyle/health care modalities, etc. would need to be updated regularly.

The language is pretty simple, clear, and easy to read.

There is no complaint about consistency. One of the main issues of writing a book, consistency was well managed by the authors.

The book is easy to explore based on how easy the setup is. Students can browse to the specific section that they want to read without much hassle of finding the correct information.

The organization is simple but effective. The authors organized the book based on what can happen in a patient's life and what possible scenarios students should learn about the disease. From that perspective, the book does a good job.

The interface is easy and simple to navigate. Some links to external sources might need to be updated regularly since those links are subject to change that is beyond the author's control. It's frustrating for the reader when the external link shows no information.

The book is free of any major language and grammatical errors.

The book might do a little better in cultural competency. e.g. Last name Singh is mainly for Sikh people. In the text Harj and Priya Singh are Muslim. the authors can consult colleagues who are more familiar with those cultures and revise some cultural aspects of the cases mentioned in the book.

The book is a nice addition to the open textbook world. Hope to see more health issues covered by the book.

Reviewed by Ryan Sheryl, Assistant Professor, California State University, Dominguez Hills on 7/16/20

This text contains 8 medical case studies that reflect best practices at the time of publication. The text identifies 5 overarching learning objectives: interprofessional collaboration, client centered care, evidence-based practice, quality improvement, and informatics. While the case studies do not cover all medical conditions or bodily systems, the book is thorough in conveying details of various patients and medical team members in a hospital environment. Rather than an index or glossary at the end of the text, it contains links to outside websites for more information on medical tests and terms referenced in the cases.

The content provided is reflective of best practices in patient care, interdisciplinary collaboration, and communication at the time of publication. It is specifically accurate for the context of hospitals in Canada. The links provided throughout the text have the potential to supplement with up-to-date descriptions and definitions, however, many of them are broken (see notes in Interface section).

The content of the case studies reflects the increasingly complex landscape of healthcare, including a variety of conditions, ages, and personal situations of the clients and care providers. The text will require frequent updating due to the rapidly changing landscape of society and best practices in client care. For example, a future version may include inclusive practices with transgender clients, or address ways medical racism implicitly impacts client care (see notes in Cultural Relevance section).

The text is written clearly and presents thorough, realistic details about working and being treated in an acute hospital context.

The text is very straightforward. It is consistent in its structure and flow. It uses consistent terminology and follows a structured framework throughout.

Being a series of 8 separate case studies, this text is easily and readily divisible into smaller sections. The text was designed to be taken apart and used piece by piece in order to serve various learning contexts. The parts of each case study can also be used independently of each other to facilitate problem solving.

The topics in the case studies are presented clearly. The structure of each of the case studies proceeds in a similar fashion. All of the cases are set within the same hospital so the hospital personnel and service providers reappear across the cases, giving a textured portrayal of the experiences of the various service providers. The cases can be used individually, or one service provider can be studied across the various studies.

The text is very straightforward, without complex charts or images that could become distorted. Many of the embedded links are broken and require updating. The links that do work are a very useful way to define and expand upon medical terms used in the case studies.

Grammatical errors are minimal and do not distract from the flow of the text. In one instance the last name Singh is spelled Sing, and one patient named Fred in the text is referred to as Frank in the appendix.

The cases all show examples of health care personnel providing compassionate, client-centered care, and there is no overt discrimination portrayed. Two of the clients are in same-sex marriages and these are shown positively. It is notable, however, that the two cases presenting people of color contain more negative characteristics than the other six cases portraying Caucasian people. The people of color are the only two examples of clients who smoke regularly. In addition, the Indian client drinks and is overweight, while the First Nations client is the only one in the text to have a terminal diagnosis. The Indian client is identified as being Punjabi and attending a mosque, although there are only 2% Muslims in the Punjab province of India. Also, the last name Singh generally indicates a person who is a Hindu or Sikh, not Muslim.

Reviewed by Monica LeJeune, RN Instructor, LSUE on 4/24/20

Has comprehensive unfolding case studies that guide the reader to recognize and manage the scenario presented. Assists in critical thinking process. read more

Has comprehensive unfolding case studies that guide the reader to recognize and manage the scenario presented. Assists in critical thinking process.

Accurately presents health scenarios with real life assessment techniques and patient outcomes.

Relevant to nursing practice.

Clearly written and easily understood.

Consistent with healthcare terminology and framework

Has a good reading flow.

Topics presented in logical fashion

Easy to read.

No grammatical errors noted.

Text is not culturally insensitive or offensive.

Good book to have to teach nursing students.

Reviewed by april jarrell, associate professor, J. Sargeant Reynolds Community College on 1/7/20

The text is a great case study tool that is appropriate for nursing school instructors to use in aiding students to learn the nursing process. read more

The text is a great case study tool that is appropriate for nursing school instructors to use in aiding students to learn the nursing process.

The content is accurate and evidence based. There is no bias noted

The content in the text is relevant, up to date for nursing students. It will be easy to update content as needed because the framework allows for addition to the content.

The text is clear and easy to understand.

Framework and terminology is consistent throughout the text; the case study is a continual and takes the student on a journey with the patient. Great for learning!

The case studies can be easily divided into smaller sections to allow for discussions, and weekly studies.

The text and content progress in a logical, clear fashion allowing for progression of learning.

No interface issues noted with this text.

No grammatical errors noted in the text.

No racial or culture insensitivity were noted in the text.

I would recommend this text be used in nursing schools. The use of case studies are helpful for students to learn and practice the nursing process.

Reviewed by Lisa Underwood, Practical Nursing Instructor, NTCC on 12/3/19

The text provides eight comprehensive case studies that showcase the different viewpoints of the many roles involved in patient care. It encompasses the most common seen diagnoses seen across healthcare today. Each case study comes with its own set of learning objectives that can be tweaked to fit several allied health courses. Although the case studies are designed around the Canadian Healthcare System, they are quite easily adaptable to fit most any modern, developed healthcare system.

Content Accuracy rating: 3

Overall, the text is quite accurate. There is one significant error that needs to be addressed. It is located in the DVT case study. In the study, a popliteal artery clot is mislabeled as a DVT. DVTs are located in veins, not in arteries. That said, the case study on the whole is quite good. This case study could be used as a learning tool in the classroom for discussion purposes or as a way to test student understanding of DVTs, on example might be, "Can they spot the error?"

At this time, all of the case studies within the text are current. Healthcare is an ever evolving field that rests on the best evidence based practice. Keeping that in mind, educators can easily adapt the studies as the newest evidence emerges and changes practice in healthcare.

All of the case studies are well written and easy to understand. The text includes several hyperlinks and it also highlights certain medical terminology to prompt readers as a way to enhance their learning experience.

Across the text, the language, style, and format of the case studies are completely consistent.

The text is divided into eight separate case studies. Each case study may be used independently of the others. All case studies are further broken down as the focus patient passes through each aspect of their healthcare system. The text's modularity makes it possible to use a case study as individual work, group projects, class discussions, homework or in a simulation lab.

The case studies and the diagnoses that they cover are presented in such a way that educators and allied health students can easily follow and comprehend.

The book in itself is free of any image distortion and it prints nicely. The text is offered in a variety of digital formats. As noted in the above reviews, some of the hyperlinks have navigational issues. When the reader attempts to access them, a "page not found" message is received.

There were minimal grammatical errors. Some of which may be traced back to the differences in our spelling.

The text is culturally relevant in that it includes patients from many different backgrounds and ethnicities. This allows educators and students to explore cultural relevance and sensitivity needs across all areas in healthcare. I do not believe that the text was in any way insensitive or offensive to the reader.

By using the case studies, it may be possible to have an open dialogue about the differences noted in healthcare systems. Students will have the ability to compare and contrast the Canadian healthcare system with their own. I also firmly believe that by using these case studies, students can improve their critical thinking skills. These case studies help them to "put it all together".

Reviewed by Melanie McGrath, Associate Professor, TRAILS on 11/29/19

The text covered some of the most common conditions seen by healthcare providers in a hospital setting, which forms a solid general base for the discussions based on each case. read more

The text covered some of the most common conditions seen by healthcare providers in a hospital setting, which forms a solid general base for the discussions based on each case.

I saw no areas of inaccuracy

As in all healthcare texts, treatments and/or tests will change frequently. However, everything is currently up-to-date thus it should be a good reference for several years.

Each case is written so that any level of healthcare student would understand. Hyperlinks in the text is also very helpful.

All of the cases are written in a similar fashion.

Although not structured as a typical text, each case is easily assigned as a stand-alone.

Each case is organized clearly in an appropriate manner.

I did not see any issues.

I did not see any grammatical errors

The text seemed appropriately inclusive. There are no pediatric cases and no cases of intellectually-impaired patients, but those types of cases introduce more advanced problem-solving which perhaps exceed the scope of the text. May be a good addition to the text.

I found this text to be an excellent resource for healthcare students in a variety of fields. It would be best utilized in inter professional courses to help guide discussion.

Reviewed by Lynne Umbarger, Clinical Assistant Professor, Occupational Therapy, Emory and Henry College on 11/26/19

While the book does not cover every scenario, the ones in the book are quite common and troublesome for inexperienced allied health students. The information in the book is thorough enough, and I have found the cases easy to modify for educational purposes. The material was easily understood by the students but challenging enough for classroom discussion. There are no mentions in the book about occupational therapy, but it is easy enough to add a couple words and make inclusion simple.

Very nice lab values are provided in the case study, making it more realistic for students.

These case studies focus on commonly encountered diagnoses for allied health and nursing students. They are comprehensive, realistic, and easily understood. The only difference is that the hospital in one case allows the patient's dog to visit in the room (highly unusual in US hospitals).

The material is easily understood by allied health students. The cases have links to additional learning materials for concepts that may be less familiar or should be explored further in a particular health field.

The language used in the book is consistent between cases. The framework is the same with each case which makes it easier to locate areas that would be of interest to a particular allied health profession.

The case studies are comprehensive but well-organized. They are short enough to be useful for class discussion or a full-blown assignment. The students seem to understand the material and have not expressed that any concepts or details were missing.

Each case is set up like the other cases. There are learning objectives at the beginning of each case to facilitate using the case, and it is easy enough to pull out material to develop useful activities and assignments.

There is a quick chart in the Appendix to allow the reader to determine the professions involved in each case as well as the pertinent settings and diagnoses for each case study. The contents are easy to access even while reading the book.

As a person who attends carefully to grammar, I found no errors in all of the material I read in this book.

There are a greater number of people of different ethnicities, socioeconomic status, ages, and genders to make this a very useful book. With each case, I could easily picture the person in the case. This book appears to be Canadian and more inclusive than most American books.

I was able to use this book the first time I accessed it to develop a classroom activity for first-year occupational therapy students and a more comprehensive activity for second-year students. I really appreciate the links to a multitude of terminology and medical lab values/issues for each case. I will keep using this book.

Reviewed by Cindy Krentz, Assistant Professor, Metropolitan State University of Denver on 6/15/19

The book covers eight case studies of common inpatient or emergency department scenarios. I appreciated that they had written out the learning objectives. I liked that the patient was described before the case was started, giving some understanding of the patient's background. I think it could benefit from having a glossary. I liked how the authors included the vital signs in an easily readable bar. I would have liked to see the labs also highlighted like this. I also felt that it would have been good written in a 'what would you do next?' type of case study.

The book is very accurate in language, what tests would be prudent to run and in the day in the life of the hospital in all cases. One inaccuracy is that the authors called a popliteal artery clot a DVT. The rest of the DVT case study was great, though, but the one mistake should be changed.

The book is up to date for now, but as tests become obsolete and new equipment is routinely used, the book ( like any other health textbook) will need to be updated. It would be easy to change, however. All that would have to happen is that the authors go in and change out the test to whatever newer, evidence-based test is being utilized.

The text is written clearly and easy to understand from a student's perspective. There is not too much technical jargon, and it is pretty universal when used- for example DVT for Deep Vein Thrombosis.

The book is consistent in language and how it is broken down into case studies. The same format is used for highlighting vital signs throughout the different case studies. It's great that the reader does not have to read the book in a linear fashion. Each case study can be read without needing to read the others.

The text is broken down into eight case studies, and within the case studies is broken down into days. It is consistent and shows how the patient can pass through the different hospital departments (from the ER to the unit, to surgery, to home) in a realistic manner. The instructor could use one or more of the case studies as (s)he sees fit.

The topics are eight different case studies- and are presented very clearly and organized well. Each one is broken down into how the patient goes through the system. The text is easy to follow and logical.

The interface has some problems with the highlighted blue links. Some of them did not work and I got a 'page not found' message. That can be frustrating for the reader. I'm wondering if a glossary could be utilized (instead of the links) to explain what some of these links are supposed to explain.

I found two or three typos, I don't think they were grammatical errors. In one case I think the Canadian spelling and the United States spelling of the word are just different.

This is a very culturally competent book. In today's world, however, one more type of background that would merit delving into is the trans-gender, GLBTQI person. I was glad that there were no stereotypes.

I enjoyed reading the text. It was interesting and relevant to today's nursing student. Since we are becoming more interprofessional, I liked that we saw what the phlebotomist and other ancillary personnel (mostly different technicians) did. I think that it could become even more interdisciplinary so colleges and universities could have more interprofessional education- courses or simulations- with the addition of the nurse using social work, nutrition, or other professional health care majors.

Reviewed by Catherine J. Grott, Interim Director, Health Administration Program, TRAILS on 5/5/19

The book is comprehensive but is specifically written for healthcare workers practicing in Canada. The title of the book should reflect this. read more

The book is comprehensive but is specifically written for healthcare workers practicing in Canada. The title of the book should reflect this.

The book is accurate, however it has numerous broken online links.

Relevance/Longevity rating: 3

The content is very relevant, but some links are out-dated. For example, WHO Guidelines for Safe Surgery 2009 (p. 186) should be updated.

The book is written in clear and concise language. The side stories about the healthcare workers make the text interesting.

The book is consistent in terms of terminology and framework. Some terms that are emphasized in one case study are not emphasized (with online links) in the other case studies. All of the case studies should have the same words linked to online definitions.

Modularity rating: 3

The book can easily be parsed out if necessary. However, the way the case studies have been written, it's evident that different authors contributed singularly to each case study.

The organization and flow are good.

Interface rating: 1

There are numerous broken online links and "pages not found."

The grammar and punctuation are correct. There are two errors detected: p. 120 a space between the word "heart" and the comma; also a period is needed after Dr (p. 113).

I'm not quite sure that the social worker (p. 119) should comment that the patient and partner are "very normal people."

There are roughly 25 broken online links or "pages not found." The BC & Canadian Guidelines (p. 198) could also include a link to US guidelines to make the text more universal . The basilar crackles (p. 166) is very good. Text could be used compare US and Canadian healthcare. Text could be enhanced to teach "soft skills" and interdepartmental communication skills in healthcare.

Reviewed by Lindsey Henry, Practical Nursing Instructor, Fletcher on 5/1/19

I really appreciated how in the introduction, five learning objectives were identified for students. These objectives are paramount in nursing care and they are each spelled out for the learner. Each Case study also has its own learning... read more

As a seasoned nurse, I believe that the content regarding pathophysiology and treatments used in the case studies were accurate. I really appreciated how many of the treatments were also explained and rationales were given, which can be very helpful to facilitate effective learning for a nursing student or novice nurse.

The case studies are up to date and correlate with the current time period. They are easily understood.

I really loved how several important medical terms, including specific treatments were highlighted to alert the reader. Many interventions performed were also explained further, which is great to enhance learning for the nursing student or novice nurse. Also, with each scenario, a background and history of the patient is depicted, as well as the perspectives of the patient, patients family member, and the primary nurse. This really helps to give the reader a full picture of the day in the life of a nurse or a patient, and also better facilitates the learning process of the reader.

These case studies are consistent. They begin with report, the patient background or updates on subsequent days, and follow the patients all the way through discharge. Once again, I really appreciate how this book describes most if not all aspects of patient care on a day to day basis.

Each case study is separated into days. While they can be divided to be assigned at different points within the course, they also build on each other. They show trends in vital signs, what happens when a patient deteriorates, what happens when they get better and go home. Showing the entire process from ER admit to discharge is really helpful to enhance the students learning experience.

The topics are all presented very similarly and very clearly. The way that the scenarios are explained could even be understood by a non-nursing student as well. The case studies are very clear and very thorough.

The book is very easy to navigate, prints well on paper, and is not distorted or confusing.

I did not see any grammatical errors.

Each case study involves a different type of patient. These differences include race, gender, sexual orientation and medical backgrounds. I do not feel the text was offensive to the reader.

I teach practical nursing students and after reading this book, I am looking forward to implementing it in my classroom. Great read for nursing students!

Reviewed by Leah Jolly, Instructor, Clinical Coordinator, Oregon Institute of Technology on 4/10/19

Good variety of cases and pathologies covered. read more

Good variety of cases and pathologies covered.

Content Accuracy rating: 2

Some examples and scenarios are not completely accurate. For example in the DVT case, the sonographer found thrombus in the "popliteal artery", which according to the book indicated presence of DVT. However in DVT, thrombus is located in the vein, not the artery. The patient would also have much different symptoms if located in the artery. Perhaps some of these inaccuracies are just typos, but in real-life situations this simple mistake can make a world of difference in the patient's course of treatment and outcomes.

Good examples of interprofessional collaboration. If only it worked this way on an every day basis!

Clear and easy to read for those with knowledge of medical terminology.

Good consistency overall.

Broken up well.

Topics are clear and logical.

Would be nice to simply click through to the next page, rather than going through the table of contents each time.

Minor typos/grammatical errors.

No offensive or insensitive materials observed.

Reviewed by Alex Sargsyan, Doctor of Nursing Practice/Assistant Professor , East Tennessee State University on 10/8/18

Because of the case study character of the book it does not have index or glossary. However it has summary for each health case study outlining key elements discussed in each case study. read more

Because of the case study character of the book it does not have index or glossary. However it has summary for each health case study outlining key elements discussed in each case study.

Overall the book is accurately depicting the clinical environment. There are numerous references to external sites. While most of them are correct, some of them are not working. For example Homan’s test link is not working "404 error"

Book is relevant in its current version and can be used in undergraduate and graduate classes. That said, the longevity of the book may be limited because of the character of the clinical education. Clinical guidelines change constantly and it may require a major update of the content.

Cases are written very clearly and have realistic description of an inpatient setting.

The book is easy to read and consistent in the language in all eight cases.

The cases are very well written. Each case is subdivided into logical segments. The segments reflect different setting where the patient is being seen. There is a flow and transition between the settings.

Book has eight distinct cases. This is a great format for a book that presents distinct clinical issues. This will allow the students to have immersive experiences and gain better understanding of the healthcare environment.

Book is offered in many different formats. Besides the issues with the links mentioned above, overall navigation of the book content is very smooth.

Book is very well written and has no grammatical errors.

Book is culturally relevant. Patients in the case studies come different cultures and represent diverse ethnicities.

Reviewed by Justin Berry, Physical Therapist Assistant Program Director, Northland Community and Technical College, East Grand Forks, MN on 8/2/18

This text provides eight patient case studies from a variety of diagnoses, which can be utilized by healthcare students from multiple disciplines. The cases are comprehensive and can be helpful for students to determine professional roles, interprofessional roles, when to initiate communication with other healthcare practitioners due to a change in patient status, and treatment ideas. Some additional patient information, such as lab values, would have been beneficial to include.

Case study information is accurate and unbiased.

Content is up to date. The case studies are written in a way so that they will not be obsolete soon, even with changes in healthcare.

The case studies are well written, and can be utilized for a variety of classroom assignments, discussions, and projects. Some additional lab value information for each patient would have been a nice addition.

The case studies are consistently organized to make it easy for the reader to determine the framework.

The text is broken up into eight different case studies for various patient diagnoses. This design makes it highly modular, and would be easy to assign at different points of a course.

The flow of the topics are presented consistently in a logical manner. Each case study follows a patient chronologically, making it easy to determine changes in patient status and treatment options.

The text is free of interface issues, with no distortion of images or charts.

The text is not culturally insensitive or offensive in any way. Patients are represented from a variety of races, ethnicities, and backgrounds

This book would be a good addition for many different health programs.

Reviewed by Ann Bell-Pfeifer, Instructor/Program Director, Minnesota State Community and Technical College on 5/21/18

The book gives a comprehensive overview of many types of cases for patient conditions. Emergency Room patients may arrive with COPD, heart failure, sepsis, pneumonia, or as motor vehicle accident victims. It is directed towards nurses, medical laboratory technologists, medical radiology technologists, and respiratory therapists and their roles in caring for patients. Most of the overview is accurate. One suggestion is to provide an embedded radiologist interpretation of the exams which are performed which lead to the patients diagnosis.

Overall the book is accurate. Would like to see updates related to the addition of direct radiography technology which is commonly used in the hospital setting.

Many aspects of medicine will remain constant. The case studies seem fairly accurate and may be relevant for up to 3 years. Since technology changes so quickly in medicine, the CT and x-ray components may need minor updates within a few years.

The book clarity is excellent.

The case stories are consistent with each scenario. It is easy to follow the structure and learn from the content.

The book is quite modular. It is easy to break it up into cases and utilize them individually and sequentially.

The cases are listed by disease process and follow a logical flow through each condition. They are easy to follow as they have the same format from the beginning to the end of each case.

The interface seems seamless. Hyperlinks are inserted which provide descriptions and references to medical procedures and in depth definitions.

The book is free of most grammatical errors. There is a place where a few words do not fit the sentence structure and could be a typo.

The book included all types of relationships and ethnic backgrounds. One type which could be added is a transgender patient.

I think the book was quite useful for a variety of health care professionals. The authors did an excellent job of integrating patient cases which could be applied to the health care setting. The stories seemed real and relevant. This book could be used to teach health care professionals about integrated care within the emergency department.

Reviewed by Shelley Wolfe, Assistant Professor, Winona State University on 5/21/18

This text is comprised of comprehensive, detailed case studies that provide the reader with multiple character views throughout a patient’s encounter with the health care system. The Table of Contents accurately reflected the content. It should be noted that the authors include a statement that conveys that this text is not like traditional textbooks and is not meant to be read in a linear fashion. This allows the educator more flexibility to use the text as a supplement to enhance learning opportunities.

The content of the text appears accurate and unbiased. The “five overarching learning objectives” provide a clear aim of the text and the educator is able to glean how these objectives are captured into each of the case studies. While written for the Canadian healthcare system, this text is easily adaptable to the American healthcare system.

Overall, the content is up-to-date and the case studies provide a variety of uses that promote longevity of the text. However, not all of the blue font links (if using the digital PDF version) were still in working order. I encountered links that led to error pages or outdated “page not found” websites. While the links can be helpful, continued maintenance of these links could prove time-consuming.

I found the text easy to read and understand. I enjoyed that the viewpoints of all the different roles (patient, nurse, lab personnel, etc.) were articulated well and allowed the reader to connect and gain appreciation of the entire healthcare team. Medical jargon was noted to be appropriate for the intended audience of this text.

The terminology and organization of this text is consistent.

The text is divided into 8 case studies that follow a similar organizational structure. The case studies can further be divided to focus on individual learning objectives. For example, the case studies could be looked at as a whole for discussing communication or could be broken down into segments to focus on disease risk factors.

The case studies in this text follow a similar organizational structure and are consistent in their presentation. The flow of individual case studies is excellent and sets the reader on a clear path. As noted previously, this text is not meant to be read in a linear fashion.

This text is available in many different forms. I chose to review the text in the digital PDF version in order to use the embedded links. I did not encounter significant interface issues and did not find any images or features that would distract or confuse a reader.

No significant grammatical errors were noted.

The case studies in this text included patients and healthcare workers from a variety of backgrounds. Educators and students will benefit from expanding the case studies to include discussions and other learning opportunities to help develop culturally-sensitive healthcare providers.

I found the case studies to be very detailed, yet written in a way in which they could be used in various manners. The authors note a variety of ways in which the case studies could be employed with students; however, I feel the authors could also include that the case studies could be used as a basis for simulated clinical experiences. The case studies in this text would be an excellent tool for developing interprofessional communication and collaboration skills in a variety healthcare students.

Reviewed by Darline Foltz, Assistant Professor, University of Cincinnati - Clermont College on 3/27/18

This book covers all areas listed in the Table of Contents. In addition to the detailed patient case studies, there is a helpful section of "How to Use this Resource". I would like to note that this resource "aligns with the open textbooks... read more

The book appears to be accurate. Although one of the learning outcomes is as follows: "Demonstrate an understanding of the Canadian healthcare delivery system.", I did not find anything that is ONLY specific to the Canadian healthcare delivery system other than some of the terminology, i.e. "porter" instead of "transporter" and a few french words. I found this to make the book more interesting for students rather than deter from it. These are patient case studies that are relevant in any country.

The content is up-to-date. Changes in medical science may occur, i.e. a different test, to treat a diagnosis that is included in one or more of the case studies, however, it would be easy and straightforward to implement these changes.

This book is written in lucid, accessible prose. The technical/medical terminology that is used is appropriate for medical and allied health professionals. Something that would improve this text would to provide a glossary of terms for the terms in blue font.

This book is consistent with current medical terminology

This text is easily divided into each of the 6 case studies. The case studies can be used singly according to the body system being addressed or studied.

Because this text is a collection of case studies, flow doesn't pertain, however the organization and structure of the case studies are excellent as they are clear and easy to read.

There are no distractions in this text that would distract or confuse the reader.

I did not identify any grammatical errors.

This text is not culturally insensitive or offensive in any way and uses patients and healthcare workers that are of a variety of races, ethnicities and backgrounds.

I believe that this text would not only be useful to students enrolled in healthcare professions involved in direct patient care but would also be useful to students in supporting healthcare disciplines such as health information technology and management, medical billing and coding, etc.

Introduction

Case Study #1: Chronic Obstructive Pulmonary Disease (COPD)

Learning Objectives
Patient: Erin Johns
Emergency Room

Case Study #2: Pneumonia

Day 0: Emergency Room
Day 1: Emergency Room
Day 1: Medical Ward
Day 2: Medical Ward
Day 3: Medical Ward
Day 4: Medical Ward

Case Study #3: Unstable Angina (UA)

Patient: Harj Singh

Case Study #4: Heart Failure (HF)

Patient: Meryl Smith
In the Supermarket
Day 0: Medical Ward

Case Study #5: Motor Vehicle Collision (MVC)

Patient: Aaron Knoll
Crash Scene
Operating Room
Post Anaesthesia Care Unit (PACU)
Surgical Ward

Case Study #6: Sepsis

Patient: George Thomas
Sleepy Hollow Care Facility

Case Study #7: Colon Cancer

Patient: Fred Johnson
Two Months Ago
Pre-Surgery Admission

Case Study #8: Deep Vein Thrombosis (DVT)

Patient: Jamie Douglas

Appendix: Overview About the Authors

Ancillary Material

About the book.

Health Case Studies is composed of eight separate health case studies. Each case study includes the patient narrative or story that models the best practice (at the time of publishing) in healthcare settings. Associated with each case is a set of specific learning objectives to support learning and facilitate educational strategies and evaluation.

The case studies can be used online in a learning management system, in a classroom discussion, in a printed course pack or as part of a textbook created by the instructor. This flexibility is intentional and allows the educator to choose how best to convey the concepts presented in each case to the learner.

Because these case studies were primarily developed for an electronic healthcare system, they are based predominantly in an acute healthcare setting. Educators can augment each case study to include primary healthcare settings, outpatient clinics, assisted living environments, and other contexts as relevant.

About the Contributors

Glynda Rees teaches at the British Columbia Institute of Technology (BCIT) in Vancouver, British Columbia. She completed her MSN at the University of British Columbia with a focus on education and health informatics, and her BSN at the University of Cape Town in South Africa. Glynda has many years of national and international clinical experience in critical care units in South Africa, the UK, and the USA. Her teaching background has focused on clinical education, problem-based learning, clinical techniques, and pharmacology.

Glynda‘s interests include the integration of health informatics in undergraduate education, open accessible education, and the impact of educational technologies on nursing students’ clinical judgment and decision making at the point of care to improve patient safety and quality of care.

Faculty member in the critical care nursing program at the British Columbia Institute of Technology (BCIT) since 2003, Rob has been a critical care nurse for over 25 years with 17 years practicing in a quaternary care intensive care unit. Rob is an experienced educator and supports student learning in the classroom, online, and in clinical areas. Rob’s Master of Education from Simon Fraser University is in educational technology and learning design. He is passionate about using technology to support learning for both faculty and students.

Part of Rob’s faculty position is dedicated to providing high fidelity simulation support for BCIT’s nursing specialties program along with championing innovative teaching and best practices for educational technology. He has championed the use of digital publishing and was the tech lead for Critical Care Nursing’s iPad Project which resulted in over 40 multi-touch interactive textbooks being created using Apple and other technologies.

Rob has successfully completed a number of specialist certifications in computer and network technologies. In 2015, he was awarded Apple Distinguished Educator for his innovation and passionate use of technology to support learning. In the past five years, he has presented and published abstracts on virtual simulation, high fidelity simulation, creating engaging classroom environments, and what the future holds for healthcare and education.

Janet Morrison is the Program Head of Occupational Health Nursing at the British Columbia Institute of Technology (BCIT) in Burnaby, British Columbia. She completed a PhD at Simon Fraser University, Faculty of Communication, Art and Technology, with a focus on health information technology. Her dissertation examined the effects of telehealth implementation in an occupational health nursing service. She has an MA in Adult Education from St. Francis Xavier University and an MA in Library and Information Studies from the University of British Columbia.

Janet’s research interests concern the intended and unintended impacts of health information technologies on healthcare students, faculty, and the healthcare workforce.

She is currently working with BCIT colleagues to study how an educational clinical information system can foster healthcare students’ perceptions of interprofessional roles.

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Systems Thinking for Public Health: A Case Study Using U.S. Public Education

ABSTRACT | The initial response to the COVID-19 pandemic in the United States largely focused on addressing the immediate health consequences from the emergent pathogen. This initial focus often ignored the related impacts from the pandemic and from mitigation measures, including how existing social determinants of health compounded physical, social, and economic impacts on individuals who have historically been marginalized. The consequences of decisions around closing and reopening primary and secondary (K–12 in the United States) public schools exemplify the complex impacts of pandemic mitigation measures. Ongoing COVID-19 mitigation and recovery efforts have gradually begun addressing indirect consequences, but these efforts were slow to be identified and adopted through much of the acute phase of the pandemic, mirroring the decades-long neglect of contributors to the overall health and well-being of populations that have been made to be vulnerable.

A systems approach for decision-making and problem solving holistically considers the effects of complex interacting factors. Taking a systems approach at the start of the next health emergency could encourage response strategies that consider various competing public health needs throughout different sectors of society, account for existing disparities, and preempt undesirable consequences before and during response implementation. There is a need to understand how a systems approach can be better integrated into decision-making to improve future responses to public health emergencies. A wide range of stakeholders should contribute expertise to these models, and these partnerships should be formed in advance of a public health emergency.

Introduction

In September 2021 the National Academies of Sciences, Engineering, and Medicine hosted a workshop titled “Towards a Post-Pandemic World: Lessons from COVID-19 for Now and the Future.” (NASEM, 2022) In this article, select workshop participants further explore the application of systems thinking in evaluating COVID-19 mitigation measures.

Systems Thinking in Public Health

A systems science approach to outbreak response planning is a useful tool for broadening strategic thinking to consider critical factors driving the short- and long-term consequences of crisis response measures, including how such decisions will impact health disparities (Bradley et al., 2020). A conceptual framework, systems thinking accounts for the relationship between individual factors within a scenario as well as their contributions to the whole, and can facilitate the synthesis of response plans that match the scale and complexity of the problem at hand (Trochim et al., 2006).

Specifically for public health, a systems approach “applies scientific insights to understand the elements that influence health outcomes; models the relationships between those elements; and alters design, processes or policies based on the resultant knowledge” (Kaplan et al., 2013). Complex and interconnected risk factors collectively influenced health outcomes in the COVID-19 pandemic. Response to an evolving public health emergency requires a systems approach that can weigh disparate needs and account for systemic inequities to quickly generate solutions while remaining adaptable as new data emerges.

In this article, we use the issue of K–12 public school closures in the United States to illustrate the need for systems approaches in public health situations. Mapping tools, such as causal loop diagrams, can show the complexity of interconnected factors and their use should be prioritized to guide evidence-based decisions in complex and evolving circumstances. This article argues for the adoption of a systems science approach to outbreak decision-making that:

addresses the inherent complexity of societal impacts during public health emergencies,
accounts for social determinants of health, and
includes perspectives from a wide range of stakeholders

COVID-19 Decision-Making and Unintended Consequences

At the start of the COVID-19 pandemic, policy decisions and responses were enacted quickly to contain the spread of disease. However, the public health implications of COVID-19 extend beyond the disease itself, as the pandemic exacerbated disparities in health outcomes closely correlated with social determinants of health and structural inequalities (Karmakar et al., 2021; Liao and De Maio 2021; Webb Hooper et al., 2020). While strong infection control measures, such as lockdowns and school closures, were considered essential when COVID-19 was an emergent disease, these responses resulted in unintended consequences that were not prioritized in the early decision-making process (Turcotte-Tremblay et al., 2021).

This trade-off may have been necessary at the time, given the rapid disease spread and lack of data about the disease to guide initial decisions. However, as the potential for containment or eradication of COVID-19 dimmed, decision-makers were slow to update mitigation measures based on evolving knowledge and accounting for the broader population health needs. The COVID-19 response stemmed largely from concern about acute infections, reflecting a mindset that was more focused on medical response than broader public health impacts.

Biological factors (e.g., age or comorbidities such as hypertension, diabetes, lung disease, or immunodeficiencies) and social determinants of health (e.g., disparities stemming from marginalized socioeconomic status, lack of access to housing and transportation, race and ethnicity, and language and literacy barriers) interact to affect health and well-being (WHO, 2023; Gao et al., 2021). While awareness of biological risk factors for severe illness grew rapidly and mitigation measures were enacted to protect individuals at risk, consideration for social risk factors in COVID response plans were not equally prioritized (Laylavi, 2021).

For example, while the federal government heavily invested in the development of vaccines and anti-viral treatments early in the pandemic (Lalani et al., 2023), expanded unemployment support to address pandemic-related job losses and educational support for students during school closures were deprioritized and debated at length in government. This inaction slowed critical support for populations disproportionately impacted by pandemic spread-related closures.

The neglect of programs that would create a social safety net for the populations most marginalized is not specific to the pandemic, but is an exacerbation of systematic neglect over decades (Mody et al., 2022; Dorn et al., 2020; Saenz and Sparks, 2020). Even when educational support programs were rolled out, they were implemented inconsistently and did not specifically consider the additional needs of populations that have been made to be vulnerable and that were more likely to be disproportionately impacted by school closures and loss of income due to pandemic restrictions (Wright, 2021).

Officials did not give significant attention to the secondary impacts of the COVID-19 pandemic as the pandemic progressed. While these social disparities existed before the onset of COVID-19, decisions made in response to the pandemic widened many of these gaps.

There have been earlier calls to apply a systems approach to improve public health outcomes, and many examples exist to illustrate the strength of a systems approach in successfully addressing complex public health challenges (Kaplan et al., 2013; Honoré et al., 2011). The example of public school closures demonstrates how the social impacts of mitigation measures widened existing disparities. The example also highlights the need for holistic, systems-based approaches in addressing future public health crises.

Public School Closures and Remote Learning: A Case for Applying Systems Thinking to Improve Health Outcomes during Future Disease Outbreaks

The issue of school closures during the pandemic serves as a case study for how factors affecting health were not holistically considered during decision-making. School closures can exacerbate social and health disparities, with long-lasting consequences (NASEM, 2020). Many students rely on school systems for adequate nutrition, safety, supervision, and socioemotional and cognitive development (Van Lancker and Parolin, 2020). In addition, substantial evidence shows that remote learning is an inadequate and unequitable substitute for in-person learning and does not completely mitigate learning losses during school closures (Agostinelli et al., 2022; Engzell et al., 2021; Bettinger and Loeb, 2017).

Furthermore, school closures may have a greater impact on students in underserved communities. Systemically disadvantaged students (e.g., those who are experiencing poverty or are from racial or ethnic minority communities) are less likely to have access to the technology or broadband internet that is necessary for remote learning. They are less likely to have parents who are able to work from home and supervise them and often encounter other barriers to achieving learning goals (Smith and Reeves, 2020). Students with special educational needs have had disproportionate learning losses and have limited access to other supportive resources otherwise provided through schools while schools are closed (Hurwitz et al., 2021; Nelson and Murakami, 2020).

Importantly, education access and achievement are associated with improved health outcomes, and the above-mentioned educational disparities may translate to worsened health disparities among the different communities (Dorn et al., 2021; Zajacova and Lawrence, 2018).

The decision-making surrounding school closures is complex (Allen, 2021; World Bank Group Education, 2020). While decision makers now know that K–12 public school children have reduced physical risk to severe disease outcomes from COVID-19 compared to adults, school closures were implemented early in the pandemic, when this risk was unknown and there was limited time for decision-making. Students experienced related impacts from pandemic mitigation measures, and some have suffered mentally, emotionally, and developmentally as a direct result of school closures specifically (Viner et al., 2022; Engzell et al., 2021).

However, decisions about school closures and transitions to remote learning at the start of the COVID-19 pandemic generally focused on physical health risk factors (e.g., preventing transmission and mortality) rather than holistic evaluations of children’s multifaceted developmental needs (e.g., socialization in cognitive and emotional development; Viner et al., 2022). Factors such as public fear and parental pressure may have also affected decisions both to close and reopen schools. Many under-resourced schools may have also had limited ability to facilitate a safe return to in-person learning. The many factors affecting school closure decisions further demonstrates the overall need for a systematic, context-specific model for decision-making in future emergencies.

Widespread school closures lasted well into 2021, despite early and repeated warnings about the potential costs to student well-being (Allen, 2021; Kaffenberger, 2021; Balingit and Meckler, 2020) and evidence that with adequate interventions, in-person schooling could be made safe (Alonso et al., 2022; Rotevatn et al., 2022; Head et al., 2021).

Furthermore, school closures were experienced unequally. A nationwide study by Parolin and Lee (2021) found a correlation between school closures in fall 2021 and the racial and ethnic composition of the student body, with nearly 70 percent in-person attendance in schools with a high majority of White students and more than 70 percent closure among schools with large proportions of non-White students. This difference was observed across the United States and within local metro areas.

For example, in Los Angeles County, schools with the highest proportion of racial and ethnic minority students stayed closed at higher rates and for longer durations than schools with the highest proportion of White students (see Figure 1 ). Many factors could have contributed to this observation, including governance, demographic distribution in urban and suburban areas, differences in resource availability in public schools (including school health services), and differences in transmission rates due to population density.

A separate study by Grossmann et al. (2021) also suggested that other outside factors, such as political pressure and strength of teachers unions, may have had significant influence over school closure decisions. A diversity of factors impact student well-being; thus, a systems approach would support informed decision-making in school closure policies.

Multiple factors must also be accounted for in remediation plans, not just initial decision-making, in response to a public health crisis. In July 2021, the Center on Reinventing Public Education (CRPE, 2022) evaluated published plans from 100 major US school districts on spending the more than $43 billion allocated from the Elementary and Secondary School Emergency Relief Fund. While most districts included learning loss and social, emotional, and mental health as key target areas for remediation, only about 30 percent of schools accounted for special needs, equity, and community engagement in their remediation plans (see Figure 2 ). This data revealed that many school districts have attempted to address pandemic-related health outcomes, but these efforts can be further improved with a more holistic approach to decision-making regarding public education and student health.

Students’ well-being and long-term health outcomes are not the only considerations in deciding when best to resume in-person learning. Plans for safe and sustainable resumption of in-person learning also need to consider the needs and concerns of other stakeholders, such as parents, school staff (including nurses and health human resources), and public officials. For example, federal school reopening strategies included practices to safeguard the well-being of educators and other school staff (Department of Education, 2021). Other concerns include the need for data to understand and mitigate transmission dynamics within classrooms and in the local community, especially with the emergence of new viral variants (Honein et al., 2021). These complexities further underline the need for a holistic decision-making strategy that accounts for different needs and dynamics as information unfolds during a public health emergency such as the COVID-19 pandemic.

Using Systems Thinking to Redefine Strategies for Public Health Preparedness

Implementing a systems approach to public health planning requires tools, trained experts, and collaboration with stakeholders. Causal loop diagrams (CLDs) are analytical tools used to map a complex set of factors and forces in a system. They can be used to analyze interplay between factors or develop response strategies. CLDs are gaining attention in public health spheres and can be developed for various purposes, including for influencing policy and practice and for system dynamics modeling (Baugh Littlejohns et al., 2021).

Several CLDs have been developed to demonstrate the variety and interconnectedness of issues related to COVID-19, including mitigation measures. In a series of workshops, Sahin et al. (2020) gathered a group of subject matter experts in various fields (e.g., public health, social science, systems thinking) to develop a CLD that maps the unintended impacts of COVID-19 mitigation measures on socioeconomic systems (see Figure 3 ). One of the loops shows that social distancing will likely decrease virus transmission but also has negative, lasting mental health consequences (loop B3). Sahin et al. (2020) note there is a “a high risk of catastrophic social order demise” if enacted policies do not account for impacts on society.

Tools such as CLDs can facilitate understanding of varying factors within a public health system, a view that is needed to enact holistic solutions. This model captures the severity of social consequences, which were largely overlooked throughout the pandemic.

To further demonstrate their potential, we have created an example CLD that highlights components that could inform a more complex CLD addressing public education issues for children (see Figure 4 ). This illustrative CLD integrates several of the factors that have been discussed in this article (e.g., children’s physical health, mental and emotional health, family stressors). While not developed with the intent of immediate application, this example CLD could be modified and used for decision-making.

An analysis of COVID-19 CLDs by Strelkovskii and Rovenskaya (2021) concluded that these tools can “draw the attention of policy makers to areas where unintended and unwanted effects may be anticipated”; they identified CLDs as useful tools for highlighting the diverse impacts of the pandemic. Their analysis also found that, while there have been numerous calls to apply systems thinking approaches to the impacts of COVID-19, there are few examples of practical applications. The authors highlighted that there have been relatively few examples of CLDs developed for COVID-19, and these have been developed for purposes other than influencing decision-making.

As with many aspects of the COVID-19 pandemic, there is an opportunity to develop tools, such as CLDs, that are more actionable and policy related. The means of developing the CLD are also critical to its use. Such development should include an interdisciplinary group of experts to capture the multiple layers of a complex system. Stakeholder and community participation in developing CLDs represent a step toward developing tools that are more comprehensive and that may be more actionable from a policy standpoint (Baugh Littlejohns et al., 2021). Collaborative groups that include experts, community members, and policy makers can be better poised to develop a dynamic model that can be useful in depicting complex social, physical, and economic relationships. These nuanced models could serve as critical tools for weighing the impacts of mitigation measures in a public health emergency, and developing system models in advance will facilitate immediate action at the onset of an emergency. While providing substantial benefits, developing CLDs also presents challenges. Because systems are inherently complex, it is difficult to capture all relevant factors in a diagram while maintaining the detail that is needed to be useful. Also, translating a CLD into action can be challenging, as evidenced by the lack of actionable CLDs that address the impacts of the COVID-19 pandemic. Despite these challenges, CLDs remain a useful tool for providing a decision-making framework in complex situations with interconnected factors.

The U.S. response strategy to the COVID-19 pandemic suffered from a lack of a holistic and systems-oriented approach to decision-making. This paper outlines the complexities that should have been considered in making the shift to fully remote learning inK–12 schools during COVID-19. There is a need to integrate diverse perspectives from interdisciplinary experts, stakeholders, and community members in developing models that influence decision-making. In the example of school closures, educators, parents, school health leaders, and community leaders are relevant stakeholders for public health decisions that affect health outcomes in schools.

Systems approaches facilitate more comprehensive assessments to inform decision-making, and CLDs are a valuable tool that can be used for response planning. Time is of the essence in a public health emergency, especially when there is minimal information about an emerging threat. Systems models can be built to respond to an emerging threat and developed as information is gained.

We assert that using CLDs as part of a systems approach can improve the transparency, inclusiveness, and credibility of the decision-making process during future public health emergencies. Systems thinking, and tools such as CLDs, should be prioritized in future public health emergencies.

Despite the widely acknowledged usefulness of CLDs, there are few examples of CLDs that were applied during the COVID-19 pandemic to influence decision-making. Partnerships between public health experts and decision-makers should be developed in advance of public health emergencies, so they will be poised to respond immediately. Further, perspectives from the economic and social sectors should also be sought, to understand the complex impact of emergencies, including the impacts of mitigation measures. Increased stakeholder engagement can result in tools that are more actionable and effective.

A commitment to incorporate systems thinking will require broadening the preparedness planning approach for public health decision-making, emphasizing the inclusion of physical and related impacts, and securing buy-in from decision-makers (Zięba, 2021; Klement, 2020). This type of thinking would also require training, so the public health workforce can learn to design and implement these methods.

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https://doi.org/10.31478/202311a

Suggested Citation

Ashby, E., C. Minicucci, J. Liao, D. Buonsenso, S. González- Dambrauskas, R. Obregón, M. Zahn, W. Hallman, and C. John. 2023. Systems thinking for public health: A case study using U.S. public education. NAM Perspectives . Discussion Paper, National Academy of Medicine, Washington, DC. https://doi.org/10.31478/202311a .

Author Information

Elizabeth Ashby, MS, is Associate Program Officer, National Academies of Sciences, Engineering, and Medicine. Charlie Minicucci, BS, is Research Associate, National Academies of Sciences, Engineering, and Medicine. Julie Liao, PhD, is Program Officer, National Academies of Sciences, Engineering, and Medicine. Danilo Buonsenso, MD, PhD, is Pediatric Infectious Disease Physician, Department of Woman & Child Health & Public Health, Fondazione Policlinico Universitario Agostino Gemelli IRCCS. Sebastián González-Dambrauskas, MD, is Founder and Chair, LARed: Red Colaborativa Pediátrica de Latinoamérica and Adjunct Professor, Departamento de Pediatría y Unidad de Cuidados Intensivos de Niños, Universidad de la República. Rafael Obregón, PhD, is Country Representative, Paraguay, UNICEF. Matt Zahn, MD, is Pediatric Infectious Disease Physician, Children’s Hospital of Orange County. William Hallman, PhD, is Professor and Chair, Department of Human Ecology, School of Environmental and Biological Sciences, Rutgers University. Chandy John, MD, MS, is Professor of Pediatrics, Indiana University School of Medicine.

Acknowledgments

Charlie Minicucci and Elizabeth Ashby contributed equally to this work.

This manuscript benefited from the thoughtful input of Jessica G. Burke , University of Pittsburgh; Erin D. Maughan , George Mason University; and Carol Walsh , National Association of School Nurses.

Conflict-of-Interest Disclosures

Danilo Buonsenso reports funding from Pfizer outside the submitted work.

Correspondence

Questions or comments about this paper should be directed to Charlie Minicucci at [email protected].

The views expressed in this paper are those of the authors and not necessarily of the authors’ organizations, the National Academy of Medicine (NAM), or the National Academies of Sciences, Engineering, and Medicine (the National Academies). The paper is intended to help inform and stimulate discussion. It is not a report of the NAM or the National Academies. Copyright by the National Academy of Sciences. All rights reserved.

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Andersen, E. & Schiano, B. , 2014. Teaching with Cases: A Practical Guide , Harvard Business School Publishing. Publisher's Version "The class discussion inherent in case teaching is well known for stimulating the development of students' critical thinking skills, yet instructors often need guidance on managing that class discussion to maximize learning. Teaching with Cases focuses on practical advice for instructors that can be easily implemented. It covers how to plan a course, how to teach it, and how to evaluate it."

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Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line (2020)

Chapter: chapter 6 - case studies: health promotion programs.

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53 6.1 Introduction The case studies and analyses presented in this chapter introduce primary source employee demographic and wellness program participation data collected from five major metropolitan transit agencies: â¢ The Indianapolis Public Transportation Corporation (IndyGo), in Indianapolis, Indiana; â¢ The Regional Transit Service (RTS), in Rochester, New York; â¢ The Transit Authority of River City (TARC), in Louisville, Kentucky; â¢ The Des Moines Area Regional Transit Authority (DART), in Des Moines, Iowa; and â¢ The Los Angeles Metropolitan Transit Agency (LA Metro), in Los Angeles, California. The analysis involved a review of descriptive literature publicly available from agencies or provided to the project team by the agencies, human resources records, insurance company records, and interviews with administrative, human resources, and health promotion program personnel. The director of human resources administration at IndyGo and the manager of wellness and benefits at RTS also participated in interviews and provided information for these case studies. In some cases, members of agency staff joined a conversation and/or provided data. Details on the project teamâs selection method for the sites included in the study are available in Appendices A and B. In the case of IndyGo, RTS, TARC, and DART, the project team conducted an analysis based on individual-level data to determine if statistically measurable benefits were associated with program participation. LA Metro did not provide individual-level data, so regression modeling was not possible for this location. For the analyses, baseline data were collected from before the comprehensive health and health promotion programs began. Also collected before, during, and after the program were individual records of absenteeism (both sick and personal days taken) and workersâ compensation payments. Measures of participation were collected as well. Specifically, the project team examined the relationship between wellness/health promotion programs (screenings, 5K runs, diet) and improved health outcomes (less absenteeism, fewer sick days) in four sites using linear regression analysis. The results for three sites showed no statistically significant measurable benefit, a finding broadly consistent with past studies. In one loca- tion (Des Moines) the participation effect was statistically significant at the 95% level; it was estimated that participation in the program resulted in a 4-hour decrease in absentee hours. This result was reasonably larger, but based on a small sample so it is unclear if it could be repli- cated or should be used to generalize about effective wellness program interventions. The analyses for TARC (Louisville) and DART (Des Moines) were structured somewhat differently from those for IndyGo (Indianapolis) and RTS (Rochester). For IndyGo and RTS, C H A P T E R 6 Case Studies: Health Promotion Programs

54 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line the control/non-participatory group was based on a structural factor, such as whether an employee was insured or not (IndyGo) or worked at a remote location as opposed to working onsite (RTS). By contrast, the participants at TARC and DART volunteered to take part in well- ness activities and wellness screenings. In these two studies, the records on voluntary partici- pation were used to measure the correlations between outcomes and wellness programs. For IndyGo, RTS, TARC, and DART, the data were tracked so that pre- and post-analysis of effects of participation on absenteeism could be properly conducted. Because data were available on gender, race, and day of hire/termination, participation in these programs could be analyzed, as could rates of turnover and other research questions. The LA Metro case study provided information on the prevalence of health conditions from its insurance companies and detailed aggregate data on wellness program participation records. Individual-level data were not made available on absenteeism or workersâ compensation, however, so a multivariate statistical analysis was not possible. This chapter discusses process-based and data-driven benefits, though the two are not always mutually exclusive. Process-based benefits can include the diversity of the wellness committee, the array of programs, and the flexibility of the schedule. Data-driven benefits can include reduced absenteeism or workersâ compensation claims. This chapter begins with the description of the programs and more process-based benefits of the programs and follows with a discussion of estimated data-driven benefits. The case studies include scalable and sustainable strategies that have been implemented by the transit agencies. The programs have multiple features, including workshops on diet and exercise, biometric screenings, targeted education to avoid common injury types (e.g., musculoskeletal), financial planning, fitness challenges, and onsite gyms. 6.2 IndyGo This case study was developed through emails and discussions with the president of Amalgamated Transit Union (ATU) Local 1070, and the director of employee services for IndyGo. 6.2.1 Background IndyGo is a municipal corporation providing public transportation to the city of Indianapolis and surrounding Marion County, Indiana. The agency operates 31 bus routes throughout the county (IndyGo n.d.). As of 2018, it has approximately 680 employees, of whom more than 500 are members of ATU Local 1070 (Russell 2018). 6.2.2 Program Startup and Development The onsite clinic and wellness program were started on January 1, 2010, as part of a binding arbitration award between IndyGo and ATU Local 1070 in response to a pending premium increase of 46% from IndyGoâs health insurer. The steep increase was the providerâs response to the high cost of IndyGoâs medical claims. To control the increase, IndyGo management (together with the agencyâs benefits consultant and with agreement from ATU Local 1070) proposed an onsite clinic and wellness program. Given the agreement to offer the onsite clinic and wellness program, the insurance provider dropped the premium increase from the pending 46% to approximately 20%. The overall savings captured by reducing the increases in insur- ance premiums benefited the program in two ways. As an incentive to participation, the agency used some of the savings to reduce the portion of the insurance premiums paid by participating employees, and additional savings helped fund the program itself.

Case Studies: Health Promotion Programs 55 6.2.3 Work Organization/Work Environment Like many other agencies, the majority of operators (approximately 55%) at IndyGo work split shifts. For many operators, this arrangement has a negative impact on their quality of life. Unless operators invest the time and expense to acquire, transport, and store their own food, having access to healthier food choices can be challenging. Onsite vending machines available in the break rooms were not stocked with healthy options. One of the top priorities of ATU Local 1070 has been to provide adequate restroom access for operators. This quality of life issue can have meaningful consequences, both short- and long-term. Before implementing the wellness program, management and union leaders worked together to address this issue. 6.2.4 Health, Wellness, and Safety Concerns From the perspective of IndyGo management, the main health concerns concerning workersâ compensation are musculoskeletal injuries; slips, trips, and falls; and vehicle accidents. According to the aggregate data from claims reports and onsite clinic data, the top health issues on the personal health side are obesity, hypertension, diabetes, prediabetes, and asthma. To address the work-related incidents and injuries, IndyGo has been incorporating ergonomics and prevention of injury into onboarding and in-service training. The union president expressed that diabetes, sleep apnea, and hypertension are the top health and wellness issues of the represented employees. Obesity is also on the rise among frontline employees, according to the local president. 6.2.5 Program Activities/Elements The IndyGo health and wellness program was made available to employees who have insur- ance through IndyGo. In 2016, approximately 88% of all IndyGo employees were covered under group health insurance. Participation was voluntary but incentivized: If employees participated in the program, they paid half of the premium (15% of the total insurance premium) compared with employees who did not participate (30% of the total insurance premium). Because of the incentive, IndyGo reported that 97% of the employees covered under the group health insurance plan elected to participate in the program (Russell 2018). To maintain their discounts on the health premiums, employees must complete the following annually: a physical, a health risk assessment, a biometric screening, a minimum of four coaching sessions, and a health activity. Some of the physical and educational activities include gardening, a Weight Watchers program, onsite exercise classes, walkârun groups, basketball tournaments, a 5K event for runners and walkers, and financial and nutrition classes. Union leadership stated that the approach has been effective because even though parti- cipants have to complete the requirements, the focus is on self-help and learning how to properly care for your health on your own. The union has been particularly pleased with the level of involvement of the onsite clinic provider because they understand the nature of the jobs performed and have developed relationships with the employees. Participants can get advice and care based specifically on the demands of their jobs. Participation in the program primarily occurs while employees are on the clock. According to the agency, getting employees to participate outside of their shifts is difficult. Efforts have been made to hold events and wellness opportunities in the community, but these activities were not well attended. âItâs a great program. I suffer from a lot of ailments and gain weight very easily. The doctor and nurses at the Activate clinic are very personal. They helped me so much and I have seen real progress. They understand how demanding the job is and our eating habits. They define different alternatives. We have good results; people are getting more conscious about fitness. Thatâs what youâll hear from most members.â âATU Local 1070 Financial Secretary

56 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line 6.2.6 Organization The human resources department oversees the onsite clinic and wellness program and all activities related to health program initiatives. IndyGo contracts with a third party that is staffed with two nurse practitioners, a part-time doctor, and medical assistants, and has a wellness committee composed of union and non-union employees that help design new activities and promote the program and initiatives. The program is funded through the IndyGo operating budget, which incorporates funding obtained through agreements with the union and the healthcare insurance provider. The 3-year contract with the current onsite clinic provider costs the transit system approximately $500,000 a year, including staff costs, clinic services (primary and urgent care), and expenses for some prescription drugs (as a one-time fill) (Russell 2018). 6.2.7 Qualitative Program Benefits Although the program did not have strong internal support from frontline workers initially, the president and financial secretary of ATU Local 1070 promoted the program and helped assure workers that information disclosed in the clinic would remain confidential (Russell 2018). Now, agency and union leaders report that there is total support for the program among the employees. Many employees have shared their positive experiences, including being screened for prediabetes or sleep apnea and having access to information about how to improve eating habits and lose weight. 6.2.8 Reported Metrics From 2010â2013, the average cost for health insurance per employee fell from $12,790 to $10,244. Between 2014 and 2017, the insurance provider changed and insurance costs fluctuated. In 2017 (under the new provider) the average insurance cost per employee was $13,004. As shown in Table 29, health claims rose from 2016 to 2017 (fourth column, percentage change) and appeared to be increasing at a similar rate in 2018 (sixth column, percentage change). Additional detailed information on medical claims (e.g., claims broken down by condition or claims dating back before 2015, before the wellness program began) was not received. 6.2.9 Method On June 15, 2018, after preliminary conversations, the project team provided IndyGo with a data use agreement stating that all dataâincluding human resources, payroll, and program participation and other related dataâwould be used only for the research project, would be handled and protected according to the requirements of the Federal Information Security Management Act (FISMA), and would be destroyed at the end of the research period. Claim Type 2016 a 2017 a PercentageChange January 1â June 30, 2018 Projected Percentage Change b Medical-paid claims $4,257,969 $5,078,484 19.27% $2,538,382 20.0% Prescription-paid claims $1,091,018 $1,494,763 37.01% $791,502 27.1% a Table not adjusted for inflation. The Consumer Price Index (CPI) in 2017 was 1.6% per the U.S. Inflation Calculator; in 2018 it was 1.9%. b Numbers in this column are based on the assumption that the monthly rate in the second half of the year is the same as the monthly rate during the first 6 months of the year. Table 29. Claims and prescriptions reported for IndyGo, 2016â2017.

Case Studies: Health Promotion Programs 57 On June 21, 2018, after a follow-up call with personnel at IndyGo, the project team sent an email requesting the following data: â¢ Excel files (or tab-delimited files) with downloads of the number of personal days and number of sick days with employee names, gender, date of birth, occupational code, and date of hire for 2009â2018 (or whichever historical years were available) for all employees; â¢ Excel files (or tab-delimited files) with downloads of workersâ compensation payments for 2009â2018 with employee names for all employees; â¢ Excel files (or tab-delimited files) with race and employee names for all employees; â¢ Names of participants by year in the health insurance program; and â¢ Names of participants by year in the health wellness program, among those eligible for the health insurance program. IndyGo provided payroll data with individual-level data from 2009 to 2018 on absences, including sick leave, personal leave, family medical leave, and leave without pay, as well as workersâ compensation data from 2012 to 2018. Because IndyGo introduced the health program in 2011, 2010 was established as the baseline year for the analysis, and all requests for data referenced 2010 as the first year. (Based on the initial interview, some early requests were made for 2009 data, but the agency later clarified that the program began in March 2011.) IndyGo further provided insurance information for employees from 2011 to 2018. Using the 97% participation rate in the program among those who carried insurance as a basis, the project team assumed that if employees carried insurance, they participated in the program. No other data were available on participation among those insured. The insurance information was merged with the absentee data based on the employeeâs name and birthdate. The data provided 36 categories of job descriptions, with several categories referring to different types of operators (e.g., full-time, part-time), as well as jobs with maintenance, and administrative roles. Employees were categorized as operators, mechanics, and administrative staff based on their job descriptions in the leave data; for example, fixed-routeâcoach operator and flexible services coach operator were defined as operators. Administrative roles were removed from the analysis because the focus was on the outcomes for frontline employees, which consisted of operators and maintenance staff. For the models, the project team analyzed the full-program effects: comparison of absen- teeism and workersâ compensation measures for 2010 (the baseline year) with measures for 2017 (the last full year of program data) or with the last full year that the employee was at IndyGo before 2017, if the individualâs employment was terminated in 2017 or before. Regression models were run using ordinary least squares to detect any potential correlation between participation in the health program and lower absenteeism. The dependent variable in the models was an overall absentee variable capturing total days of leave, and the inde- pendent variables were participation/insurance (the key explanatory variables) and control variables, including age, race, tenure, gender, and occupation. The regression model was run using alter native dependent variables to measure the robustness of the model and results to different specifications. Two of those alternatives were workersâ compensation dollars and the difference of absenteeism and workersâ compensation before and after the introduction of the health program. 6.2.10 Workforce Characteristics To be included in the analysis, employees had to have been employed with IndyGo for at least 1 full calendar year in 2010 and for 1 full calendar year after the wellness program began in 2011. This qualification applied to 252 records. The workforce under observation was smaller than the total workforce due primarily to missing data and high turnover. In 2010,

58 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line IndyGo had 333 frontline employees. Twenty-one employees were excluded for missing data required in the regression analysis, and 60 employees were excluded because their employ- ment was terminated before the first complete year of the program. This left 252 records avail- able for the analysis. Table 30 presents race, age, and gender breakdowns for the two employee types (operator and maintenance, separate and combined) considered in the analysis. The White population was substantially older than the African-American population: The average age for the 53 White workers was 60.1 years, compared with an average age of 53.6 years for the 220 African-American workers. The men were slightly older than the women, averaging 56.5 years of age for men compared with 52.2 years for women. The maintenance workers were older than the operators, with an average age of 58.5 years compared to 54.7 years, and maintenance workers tended to be male at a higher rate (93.1%) than did operators (56.2%). The analysis examined if outcomes related to absenteeism were related to participation in the program. Thus, the analysis divided the population of frontline employees into two groups: âever in programâ and ânever in program.â Table 31 displays the characteristics of these two groups. Based on employees having insurance through IndyGo, the average age of participants in the program was slightly younger (53.7 years) than the average age of non-participants (57.0 years). As Table 31 shows, participants in the program were overwhelmingly operators (only one maintenance worker had been in the program). 6.2.11 Absentee Hours After Program Initiation The data generated from the IndyGo health promotion program provided a wealth of new information in an area where data have been sorely lacking. Figure 5 presents the average annual absentee hours for frontline employees for the 8 years from 2010â2017. The figure illustrates the trend in absentee days, starting with the year before the program began (2010) and extending through the last full calendar year in which data were provided. The graph presents absentee hours over time for all employees (orange line), women (purple), and men Demographic Characteristic Operator Maintenance All Count Percent Age a Count Percent Age a Count Percent Age a African American 191 85.7% 53.9 7 24.1% 50.0 198 78.6% 53.6 White 31 13.9% 59.7 22 75.9% 61.2 53 21.0% 60.1 Other race 1 0.4% 60.0 0 0% N/A 1 0.3% 60.0 Female 87 39.0% 52.5 2 6.9% 48.9 89 35.3% 52.2 Male 136 60.9% 56.2 27 93.1% 59.2 163 64.7% 56.5 Total 223 100.0% 54.7 29 100.0% 58.5 252 100.0% 55.0 a All ages are averages. Table 30. Demographics of IndyGo frontline population, 2010. Demographic Operator Maintenance AllCount Percent Age * Count Percent Age * Count Percent Age * Ever in program 153 68.6% 53.9 1 3.4% 38.6 154 61.1% 53.7 Never in program 70 31.4% 56.4 28 96.6% 59.2 98 38.9% 57.0 Total 223 100.0% 54.7 29 100.0% 58.5 252 100.0% 55.0 * All ages are averages. Table 31. Program participation and age by job category, IndyGo.

Case Studies: Health Promotion Programs 59 (teal), and for African Americans (blue) and Whites (red). Absentee hours were defined as total hours of sick leave, personal leave, and sick unpaid leave. Although year-to-year fluctuations occurred for all six groups, the general trend does not demonstrate much variation. Beginning with an average of 70 hours in 2010, there was a slight increase over the 8-year period to approximately 100 hours at the end (2017), which might reflect an aging workforce. Women on average have slightly higher amount of sick leave than men, which was a trend evident among all the case study populations. Figure 6 shows the trends as plotted for the median annual absentee hours. Figure 7 presents the average annual absentee hours for frontline employees for the eight years from 2010â2017. The graph shows maintenance employees (blue), operator employees (red), and total frontline employees (orange). 6.2.12 Workersâ Compensation Table 32 shows the number of indemnity claims for the years the agency providedâ specifically, annual data for frontline employees from 2013 through 2017. These claims could not be matched with individual employees (participants or non-participants). The table 0 20 40 60 80 100 120 140 160 2010 2011 2012 2013 2014 2015 2016 2017 Black or African American White Other Female Male Grand Total Figure 5. Average annual absentee hours, IndyGo frontline employees by race and sex, 2010â2017. 0 10 20 30 40 50 60 70 2010 2011 2012 2013 2014 2015 2016 2017 Black or African American White Female Male Grand Total Figure 6. Median annual absentee hours, IndyGo frontline employees by race and sex, 2010â2017.

60 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line illustrates the variation from year to year in both the number of claims and the average dollar- amount per claim. Figure 8 shows the percentage of (frontline) employees with indemnity claims from 2013 through 2018, including the total of employees with claims (orange), and the percentages for various demographic groups. As discussed above, data on claims before 2013 were not available. The percentage of claims increased over the observed period; thus, there was no evidence of a reduction in claims attributable to the program during this period. The program may have caused a reduction, but other (unobserved) factors would have had to offset that reduction, causing the overall rate to rise. Note that women filed the highest percentage of claims consis- tently throughout the period. 6.2.13 Results Using regression analysis, the project team investigated using several model specifications. The analyses varied the dependent variable, changed the mix of independent variables, and tested several interaction terms. The interaction terms tested how program participation varied by some of the demographic variables. In no case was the coefficient on the effect of program participation statistically significantly different from zeroâthat is, in no case did participa- tion have a statistically significant effect on health, measured as the change in number of days absent. Variables also were included for operators and maintenance, which would have shown if one occupational group was more likely to have reduced absenteeism days associated with the program than the other group. However, variables in those regressions did not have any statistically significant effects either. 0 20 40 60 80 100 120 2010 2011 2012 2013 2014 2015 2016 2017 Maintenance Operator Grand Total Figure 7. Average annual absentee hours, IndyGo frontline employees by job classification, 2010â2017. Year Sum of Claims Unique Claims Average per Claim 2013 $122,890 125 $983 2014 $228,239 336 $679 2015 $426,234 125 $3,409 2016 $956,551 336 $2,847 2017 $49,534 64 $774 Table 32. Workersâ compensation indemnity claims by year, frontline IndyGo employees, 2013â2017.

Case Studies: Health Promotion Programs 61 Appendix C outlines some of the potential reasons for the lack of significance for the participation variables. In particular, Tables C-1 and C-2 present two regressions that are representative of the variations that were tested, and the corresponding text includes a discus- sion of the analysis. 6.3 RTS This case study was developed with input from the director of well-being and inclusion and the director of people, performance, and development at RTS, and the president of ATU Local 282. 6.3.1 Background RTS is the public transportation agency that provides service to the counties of Monroe, Genesee, Livingston, Ontario, Orleans, Seneca, Wayne, and Wyoming in New York State. The agency serves more than 17 million customers annually and employs more than 900 individuals, of whom approximately 75% are operators and maintenance employees. As the largest subsidiary of the RochesterâGenesee Regional Transportation Authority, RTS has a fleet of 216 buses (of the authorityâs total fleet of 404) and has built a reputation for on-time perfor- mance and innovative performance management (RochesterâGenesee Regional Transporta- tion Authority n.d.-c). Approximately two-thirds of RTS employees are based at the agencyâs Monroe campus, which is the location of an onsite gym and the hub of the agencyâs health promotion activities. The other employees are based at nine offsite locations remote from the Monroe campus and do not have immediate access to the gym. The employees based at the offsite locations have limited access to the agencyâs health promotion activities. The data provided by RTS and the RochesterâGenesee Regional Transportation Authority used codes to represent employees at the main locations, including the nine offsite locations: Lift Line, BBS, STS, WATS, WYTS, OTS, CATS, GTC, and LTS. 6.3.2 Program Startup and Development RTSâs health and wellness program, dubbed Healthy U, started in 2011 as a modest and loosely defined program with a focus primarily on physical fitness. It became a more 0 0.02 0.04 0.06 0.08 0.1 0.12 0.14 2013 2013.5 2014 2014.5 2015 2015.5 2016 2016.5 2017 2017.5 2018 Black or African American White Female Male Grand Total Figure 8. Percentage of employees with workersâ compensation indemnity claims, by demographic group, IndyGo frontline employees, 2013â2017.

62 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line developed wellness program in 2013 and 2014, addressing a comprehensive set of goals that were defined in 2014. With healthcare costs skyrocketing and premiums rising both for the agency and the covered employees, RTS understood that it had an opportunity and an obli- gation to help employees. The agency hired a full-time health and wellness coordinator to oversee the newly expanded program. As the program was developed, medical claims data were examined to understand the most prevalent and costly medical conditions. Combining this knowledge with information about the demographics of the frontline employees, RTS staff members crafted the initial focus of the program. The agency conducted a survey in 2014 to understand the needs of transit employees, the types of programs they would be most likely to participate in and benefit from, and the most convenient times to hold events. The agency received 153 responses to the survey. In 2018, RTS conducted a similar survey to gather feedback on the wellness program. The latter survey asked respondents whether they had participated in wellness activities in the past and asked respondents to identify what would motivate them to participate in the future and whether there were any barriers that prevented their participation. This survey found that 52 respondents had participated in previous health promotion activities (RTS 2018). 6.3.3 Work Organization/Work Environment At RTS, almost all operators work split shifts (either two or three shifts). Generally, employees are on the clock between 9 hours and 12 hours, including breaks between runs. The maximum amount of time behind the wheel is 12 hours, however, and the maximum shift time is 15 hours. Bus maintenance requires coverage 24 hours a day, 7 days a week. Approximately 10% of bus technicians work split shiftsâtwo sets of scheduled times within a 7-day span. A tech- nician may work, for example, from 11:00 a.m. to 7:00 p.m. for three days, then from 3:00 p.m. to 11:00 p.m. for the remaining days of the work week. Vacation time is based on accrued personal time, and vacation leave is approved and sched- uled for the entire upcoming year. Every employee also is allowed nine sick time and/or unapproved absences per year. If the number of unapproved absences exceeds nine, employees enter disciplinary action. Operators can apply for approved time off by putting in their name and the requested date(s). As long as the employee has sufficient accrued time to cover the requested leave, approved time off does not count as an unapproved absence (RTS 2018). Shift work and varied schedules have an impact on workersâ access to healthy food and sleep patterns. Employees working overnight shifts have access to vending machines onsite, but due to the hours, the availability of alternative healthy food options is limited in the community. Sleep schedules also can be impacted by working overnights. Many bus cleaners who work overnight shifts also work a second job during the daytime, which can result in added stress, limited access to healthy food and healthcare services or support, and irregular meal times. RTSâs health insurance provider issues annual data showing the prevalence of health condi- tions. The top three conditions for 2017â2018 were hypertension (affecting 25.1% of the insured population), cholesterol disorders (16.8%), and back and neck problems (10.2%). The union president considers sleep apnea, diabetes, hypertension, and muscular issues (primarily back and shoulder) as the primary reasons leading to potential medical disqualification among operators (Chapman, personal communication, 2018). The union also cited anxiety and stress and poor nutrition as the top health and wellness concerns.

Case Studies: Health Promotion Programs 63 6.3.4 Program Activities/Elements Healthy U has promoted healthier behavior and habits among RTS employees by providing a comprehensive set of new offerings and services and changing existing services to align with the goals of the program. Many of the adjustments have focused on food because this is an accessible way to build relationships with employees. The new programs and offerings were designed to be convenient and fun to encourage participation (e.g., short workshops in the break room, bowls of fresh fruit, team activities). The program also prompted changes to regular events and services that employees engage with (e.g., by providing healthier choices in vending machines and at employee events). RTS has made efforts to provide services that fit into the daily schedule of its employees. Agency employees have 24/7 access to a wellness center that includes a gym. Employees also can make individual appointments with a health and wellness coordinator. The health and wellness coordinator works full time, which provides some flexibility for operators and other employees with off-hour shifts. The program also offers vouchers that employees can use to obtain produce from a local farmerâs market at their convenience. Employeesâ schedules, which are characterized by working shifts around the clock and on weekends, inhibit their participation in various parts of the wellness program. The wellness team and coordinator have tried to create programs that can be used at any time, with the hope of making it as easy as possible to engage all employees, regardless of what shifts or days they work. There is no feasible way to make the program accessible to everyone all the time, however. RTS promotes the Healthy U program through newsletters, posters and flyers, email blasts, paycheck attachments, and home mailings. Employees also can find information on the agencyâs intranet (Rochester Business Journal 2016). One of the most effective ways of promotion is through the support and engagement of the agencyâs Wellness Committee, whose members keep their coworkers and teams up to date on activities and eventsâand encourage their coworkers to participate. From each regional property, the RTS regional manager selects one employee (who may have a personal interest in wellness or be interested in a develop- ment opportunity) to participate as a wellness champion. Wellness champions participate in a monthly conference call to share ideas and collaborate on wellness-related topics, outreach, and events. Wellness champions do not receive extra compensation for their participation. The president of ATU Local 282 helps communicate information about the program to the unionâs members. 6.3.5 Organization The People Department (Human Resources Department) manages RTSâs health and well- ness program, which employs the full-time wellness coordinator. The Wellness Committee is staffed by representatives from every division and meets once a month to oversee the program. This committee is made up of 16 employees, including one ATU member, and two representa- tives from the agencyâs health insurance provider. Participation in the Wellness Committee is voluntary and members are not compensated extra. The President of ATU Local 282 also is personally involved in many health and wellness events organized by the agency. RTS has recently enacted a âCommitment to Diversity and Inclusion,â which the agency posits will impact the overall health and well-being of the organization and all employees by creating a more inclusive atmosphere that favors respect and relationships. A council of 16 employees, of whom 7 are frontline workers and ATU members, is responsible for carrying out the new effort, working in tandem with the wellness committee. Example of Sustainable, Successfully Implemented Strategy â¢ Connecting around food: â¢ Fresh fruit in breakrooms and common areas; â¢ Snack of the month; â¢ Short workshops on nutrition and cooking; â¢ Healthier vending machine choices; â¢ Catered employee events featuring âgood-for-youâ options; â¢ Voucher program for local farmerâs market and other onsite experiences.

64 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line 6.3.6 Resources The Healthy U program relies on third-party providers and community partners for many of the services offered. RTS funds the program through its operating budget. In fiscal year 2017â2018, the program budget was $24,320, not including the salary for the wellness coor- dinator (RochesterâGenesee Regional Transportation Authority n.d.-a). The budget covers these key categories: blood pressure kiosks onsite; equipment and supplies for the wellness center (onsite fitness facility); health screenings; food for events; promotional items; well- ness initiatives linked to claims management; and other wellness initiatives and employee engagement. For fiscal year 2018â2019, the budget was increased by $17,000 (a substantial 70%) to $41,320. 6.3.7 Qualitative Program Benefits From the perspective of the agency, the wellness program has been a successful endeavor. It has brought the organization together and fostered greater employee engagement. Despite the lack of financial incentives for participation, program engagement and utilization have increased. According to the director of well-being and inclusion, one of the greatest difficulties regarding the participation of operators is scheduling. The majority of RTS bus operators work in shifts with prolonged breaks in between, but the breaks seldom align with planned wellness events. Some success has resulted from efforts to encourage supervisors to communicate with operators and promote the program by word of mouth. According to the union president, operators that have schedules consisting of three shifts participate in wellness events to a lesser extent because of the length of their workdays. Employees with irregular work schedules find it easier to participate in events that are sched- uled on weekends or programs that are available to employees at their discretion (including the produce voucher program). Increased physical activity due to the availability of the gym is the most apparent benefit of the program, though only employees that work at the Rochester campus use it regularly due to the proximity. 6.3.8 Reported Metrics The project team examined statistics from RTSâs health insurance provider (Table 33). As seen in the table, the prevalence rates of most of the major disorders that occur in the transit worker population showed slight increases among RTSâs insured population. Because the aggregate figures provided included administrative workers and covered dependents as well as frontline workers, it was not possible to isolate the effects of participation in the wellness program. Participation in the wellness program may have mitigated increases in prevalence âRTS wants our employees to thrive and live the healthiest lives they can. The RTS Healthy U wellness program fosters a culture of health and well-being within our organization and community by empowering our employees to make healthy lifestyle choices. The strategic initiatives we are implementing for the wellness program will support employees by providing education, resources, support, and access to programs and services that are fun, engaging, and sustainable. Healthy U brings employees together on their wellness journey and celebrates their successes.â âRenee Ellwood, Director of Well-Being and Inclusion Disorder 4 Years Prior Current Change General Population (Excellus) Cholesterol disorder 30.2% 29.0% â1.2% 18.9% Hypertension 38.8% 41.9% 3.1% 23.2% Diabetes 15.4% 16.7% 1.3% 8.1% Back and neck problems 8.5% 12.9% 4.4% 14.9% Depression and anxiety 5.3% 5.9% 0.6% 9.6% Source: Table as provided by RTS via personal communication (Excellus 2018). Table 33. Comparison of rates of major health disorders, RTS insured population to general population, 2012â2017.

Case Studies: Health Promotion Programs 65 among the frontline workers that were part of a more general health trend; however, lacking the necessary granularity in the data, that hypothesis could not be assessed. RTS continues to conduct ongoing review and analysis of the health claims data and monitor wellness initia- tives against claims data (RochesterâGenesee Regional Transportation Authority n.d.-b). In addition to health claims data, new conditions are identified through free, onsite health screenings. RTS seeks to educate and bring awareness to employees about potential health risks and to prevent or manage them. The focus on prevention has resulted in the identifica- tion of more employees with health risks, but this identification has also made it possible for employees to help manage those risks, using the Healthy U wellness program to make healthy lifestyle choices. The program also has focused on the importance of managing health condi- tions and prescriptions, as well as actively using the comprehensive health and wellness benefits provided to employees (e.g., insurance coverage for medical, dental, and vision services, and other employee benefits related to financial wellness and retirement planning). 6.3.9 Method The project team provided RTS with a data use agreement, and data received from RTS associated individuals with their employee ID numbers, thereby protecting their identities. Following conversations with relevant staff members, the project team emailed a list of the absenteeism, workersâ compensation, and demographic data requested. In August 2018, RTS began providing the project team with individual-level payroll data on absences and workersâ compensation. RTS provided absenteeism and workersâ compensation data from 2011 to 2018 for both onsite and offsite employees. Files of employeesâ demographic information were provided, as well as hire and termination dates. This information was merged with the absentee data based on the employee ID. Because RTS had indicated that it introduced the health program as a comprehensive program in 2014, 2013 was used as the baseline year for the analysis. Payroll information was made available for more than 1,000 employees who had worked for RTS over the 2010â2017 period. Approximately 650 employees were onsite and had the easiest access to the health program. The entity code âRTSâ was used to identify employees who were onsite and had access to the health program, whereas the rest of the employees were combined into a control group of âoffsiteâ employees who were assumed to have limited-to- no-participation in the program. The data provided 282 categories of job descriptions, with several categories referring to different types of operators, maintenance, and administrative roles. Employees were catego- rized using the âAssignment Titleâ provided with their demographic information. For example, employees with the title bus operator were defined as operators, whereas an employee with the title workforce development manager was defined as administrative. Employees often had multiple assignment titles without a date-of-job change. To determine the job description, the project team selected the last available job title that was not retiree. Trainee was selected as the job title only if it was the only title available. Administrative roles were removed from the analysis, which focused on the outcomes for frontline employees (consisting of operators and maintenance staff). Multiple variables of interest were compared, including use of sick days, unpaid leave, and personal days. At RTS, employees acquire sick leave and personal leave at varying rates based on seniority; up to 120 days of sick leave can be accumulated (Hall, personal communication, 2018). For each variable, the difference in use before and after the introduction of the health pro- gram was examined. Multiple regression and other statistical analyses were run to find a relation- ship between participation in the health program and lower absenteeism.

66 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line In the model, the dependent variable was a total of sick days, unpaid leave, and personal days. The key independent variable was participation in the health program. The other inde- pendent variables controlled for age, race, tenure, gender, and occupation. The regression model also was run using the difference of the dependent variable before and after the intro- duction of the health program as the dependent variable. No statistically significant results were found. Details of the analysis are provided in Appendix A. 6.3.10 Workforce Characteristics In 2011, a limited version of the program was introduced, but the comprehensive version of the program was not rolled out until 2014, so the project team chose 2013 to be the base- line year for this analysis. Of the 574 frontline workers (operators and maintenance) who were employed in 2013, 389 workers (approximately 68%) were based at the main location where the gym and wellness programs were held, whereas 185 workers (32%) were based at remote locations. The project team designated the 389 workers at the main location as the participants because they had greater exposure to the programâs core elements. The 185 offsite employees were considered the control group of non-participants. Table 34 presents the averages for the total population of frontline employees, broken down separately for operators and maintenance employees. The first demographic detail that stands out is the same as for IndyGo: The White popu- lation is substantially older than the African-American population. The average age for the 300 White workers that were operators or in maintenance was 60.2 years, compared with the average age of 53.0 years for African-American workers. Men were slightly older than women, with an average age of 57.1 years compared with 54.3 years. As in Indianapolis, the population of maintenance workers was almost all male (106 out of 108 workers). The analysis method was to examine how outcomes related to absenteeism were related to program participation. Thus, the analysis divided the population of frontline employees into two groups: onsite and offsite. These groups represented the workers who participated in the program and those who did not. The characteristics of the two groups are displayed in Table 35. The average age of offsite operators (61.0 years) exceeded that of onsite operators (54.3 years). The average age of offsite maintenance workers (55.0 years) was only slightly lower than that of onsite maintenance workers (55.8 years); however, the vast majority of maintenance workers were onsite, with 101 of the 108 workers on location at the main campus. Calculating the total Demographic Characteristic Operator All Count Percent Age * Count Percent Age * Count Percent Age * White 237 50.9% 61.0 63 58.3% 57.3 300 52.3% 60.2 African American 183 39.3% 53.1 36 33.3% 52.4 219 38.2% 53.0 Hispanic and Latino 2 0.4% 60.5 0 0.0% 0.0 2 0.3% 60.5 Two or more races 2 0.4% 66.0 0 0.0% 0.0 2 0.3% 66.0 Native American 1 0.2% 41.0 2 1.9% 52.0 3 0.5% 48.3 Asian 41 8.8% 48.6 7 6.5% 58.3 48 8.4% 50.0 Female 117 25.1% 54.3 2 1.9% 53.0 119 20.7% 54.3 Male 349 74.9% 57.6 106 98.1% 55.7 455 79.3% 57.1 All 466 100.0% 56.8 108 100.0% 55.6 574 100.0% 56.5 * All ages are averages. Maintenance Table 34. Demographics of RTS frontline population, 2013.

Case Studies: Health Promotion Programs 67 populations of offsite workers (non-participants) and onsite workers (participants), the offsite workers were older (60.8 years) than the onsite workers (54.7 years). (The calculated numbers do not appear in the table.) 6.3.11 The Program Over Time As with IndyGo, data generated from RTSâs health promotion program has provided new information to assess the patterns of absenteeism of transit workers. Absenteeism days are defined as total hours of sick leave, unpaid sick leave, and paid and unpaid personal leave. Between 2011 and 2017, the total hours taken increased from approximately 40 to 60 hours per year. Figure 9 presents the average annual absentee hours for frontline employees for a 7-year period (2011â2017). The baseline in this analysis is 2013 and the comprehensive program began in 2014, but this case study includes some available data from 2011 when the health promotion program was introduced in a limited form. Figure 9 includes absen- teeism data from the early years of the program, before it was fully established (2011â2013), and from the subsequent years (2014â2017) that reflect absenteeism after the program was fully developed. The data in Figure 9 show that Whites had higher rates of absenteeism than did African Americans and that the rate of absenteeism among women was similar to that of men (not greater, as was the case at IndyGo). The data in Figure 9 have not been controlled for age. Figure 10 shows trends related to absenteeism by job category for operations, maintenance and all workers. As seen in the figure, during the period examined (2011â2017), maintenance workers had a higher average number of hours absent than did operators. Factor Operator Maintenance Offsite Onsite Offsite Onsite Number 178 288 7 101 Percentage 38.2% 61.8% 6.5% 93.5% Average age 61.0 years 54.3 years 55.0 years 55.8 years Table 35. Program status and age of RTS frontline population, 2013. 0 20 40 60 80 100 120 2011 2012 2013 2014 2015 2016 2017 Black or African American White Hispanic or Latino Female Male Grand Total Figure 9. Average annual total absentee hours, RTS frontline employees by demographic characteristics, 2011â2017.

68 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line Figure 11 presents the average annual total of absentee hours for RTS frontline employees for 2011â2017. On average during this 7-year period, onsite employees used fewer sick days then did offsite employees. 6.3.12 Workersâ Compensation Whereas Figures 9, 10, and 11 show trends related to absenteeism, Table 36 uses data provided by RTS to illustrate trends related to workersâ compensation over the same period (2011â2017), although data for 2013 and 2014 were not available. Table 36 presents workersâ compensation indemnity claims for the period and the average cost per unique claim. Table 37 includes the estimated number of days of workersâ compensation paid for all claims and the average number of days per claim. The claim percentage rate in 2011 (before program implementation) was 8%, and the percentage rate also was 8% in 2016â2017, well into the program. The percentage rose to 11% in 2012 but was reduced to 5% in 2015 (the next available year). The linear downward trend may indicate some effect due to the wellness programs, particularly if other (undocumented) factors were working at the same time to increase the percentage. It was not possible to statistically test these possibilities. 0 20 40 60 80 100 120 2011 2012 2013 2014 2015 2016 2017 Maintenance Operator Grand Total Figure 10. Average annual total absentee hours, RTS frontline employees by job classification, 2011â2017. 0 20 40 60 80 100 120 2011 2012 2013 2014 2015 2016 2017 Offsite Onsite Grand Total Figure 11. Average annual total absentee hours, RTS frontline employees by work location (onsite/offsite), 2011â2017.

Case Studies: Health Promotion Programs 69 Total workersâ compensation days were calculated based on the 2017 average wage for 731 RTS operators and maintenance workers of $24.32 and the workersâ compensation payment of 66.67% of that wage to fully disabled workers in the state of New York. 6.3.13 Results Several variations of the linear regression were performed, the results of which are presented in Appendix A. The project team varied the dependent variable (e.g., sick day, total leave days), changed the mix of the independent variables, and tried several interaction terms of program participation (e.g., onsite as interacted with various demographic variables). In no case was the coefficient on the effect of program participation statistically significantly different from zero. Similarly, in no case did participation have a statistically significant effect on health, measured as the change in days absent. Appendix C discusses potential reasons for the lack of significance for the participation variables and Table C-3 presents representative regression results of the variations run, accompanied by analysis. 6.4 TARC This case study was developed with the input of the president of ATU Local 1447 and the benefits manager at TARC. 6.4.1 Background TARC provides public transportation to greater Louisville, Kentucky, and the surrounding counties of Clark and Floyd in Indiana. The agency was founded in 1971 after legislation allowed the use of local funding from city and county governments to operate mass-transit systems (TARC n.d.). Table 36. Workersâ compensation indemnity claims at RTS, 2011â2017. Year Sum of Claims Unique Claims Average Cost per Claim 2011 $77,532 36 $2,154 2012 $225,487 47 $4,798 2013 Unavailable Unavailable Unavailable 2014 Unavailable Unavailable Unavailable 2015 $116,875 29 $4,030 2016 $512,173 46 $11,134 2017 $638,591 50 $12,772 Table 37. Workersâ compensation indemnity claims and calculated absentee days at RTS, 2011â2017. Year Unique Claims Frontline Workers Percentage With Claims Total Indemnity Claims Total Workersâ Compensation Days Average Days per Claim 2011 36 447 8% $77,532 604 16.8 2012 47 447 11% $225,487 1756 37.4 2013 N/A 468 N/A N/A N/A N/A 2014 N/A 531 N/A N/A N/A N/A 2015 29 549 5% $116,875 910 31.4 2016 46 582 8% $512,173 3,988 86.7 2017 50 592 8% $638,591 4,972 99.5

70 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line 6.4.2 Program Startup and Development The employee wellness program began in 2015 with the goal of changing workplace culture as prompted by an observed need for smoking cessation programs. The agency was further motivated to start a program that would reduce health insurance claims, which were relatively high. In 2015, TARC began offering smoking cessation classes, bringing together a motivated group of individuals that evolved into a more organized health and wellness committee. 6.4.3 Work Organization/Work Environment Many operators at the agency work split shifts, which can take up a majority of the employeeâs time, although breaks can be scheduled that allow for meals or time at the gym. Operators feel that they have time for little else besides resting for the next day. Operators can request specific shifts at three points during the year, when shifts are scheduled. Eligible operators also have the option of working four 10-hour runs and taking weekends off plus one additional day off during the week. Parameters for split runs are governed by the bargaining agreement with the union, and during the period examined by the project team TARC was well under the threshold designated for split runs. From the perspective of the union president, the agency has prioritized restroom access for operators; this issue has improved over time. According to management, the agency has worked to establish ample restroom stops on every route. 6.4.4 Health, Wellness, and Safety Concerns According to the prevalence rates reported by TARCâs health insurance company, the five most prevalent health concerns by number of members (employees and family members) for 2015â2018 were hypertension, hyperlipidemia, back pain, osteoarthritis, and diabetes. In interviews with TARC management, obesity-related diseases were a common concern. TARC reported approximately 15â20 short-term medical disqualifications per year. The disqualifi- cations increased over the period examined, mostly due to non-compliance with sleep apnea requirements. According to the union president, the top health and safety concerns are passenger assaults on operators, operator injury resulting from equipment in the bus or accidents involving the bus, and breathing in harmful fumes. According to the union president, these health concerns are not addressed in the wellness program because they are categorized primarily as âsafetyâ concerns and are dealt with separately under the joint safety committee. (Hamilton, personal communication, 2019). 6.4.5 Program Activities/Elements TARCâs wellness program activities have been based on survey responses from employees indicating the activities they would be interested in. Though the initial program was developed around smoking cessation, this is no longer a primary focus of the program, and was not an item that received interest in the most recent employee survey. Currently, the program consists of events and programs organized around a theme of interest, an annual corporate games weekend, and a boot camp program. Tracking data on participation has been an area of difficulty for the agency, but TARC has seen some success in encouraging participation by offering incentives and prizes to participants. According to the agency, these items are low cost ways to promote participation and camaraderie. TARC has also invested in creating onsite fitness centers at each of the agencyâs main facilities, which the agencyâs health insurance company has rewarded by issuing a premium refund to the agency and employees. Highest-scoring items from employee interview survey: â¢ Walking to increase physical activity, â¢ Having healthy snacks available for purchase at work, â¢ Increasing my physical activity level, â¢ Participating in âtastingâ events, and â¢ Learning about healthier food choices and portions to help manage my weight.

Case Studies: Health Promotion Programs 71 Specific program activities include weekly yoga classes, 5K runs and participant preparation assistance, periodic weight loss/weight maintenance challenges, walking events, and bioscreen- ings. A point system for participation allows employees to earn small prizes, such as exercise accessories, gear, or gift cards. 6.4.6 Organization The employee wellness program is led by a six-person health and wellness committee made up of representatives from TARCâs Human Resources Department and members of ATU Local 1447, including its president, an operator, and a mechanic. The committee meets every other month to determine upcoming program elements and themes. According to the union president, the relationship between labor and management regarding the program is cooperative. The union encourages participation in wellness program events and activities. 6.4.7 Resources The employee wellness program is funded through TARCâs Human Resources Depart- ment. In fiscal year 2018, $10,000 was budgeted for the agencyâs fitness centers and wellness program. The wellness program also has relied on the portion of the health insurance premium refund retained by the agency after premium refunds were distributed to the participating employees. 6.4.8 Qualitative Program Benefits The union president said that the program has been effective in promoting physical activity, although it is not clear whether the employees who have participated are those who would already be active independent of the program. Events are primarily attended by the same group of people, and the program has not broadly affected the employee population. Management at TARC noted that the activities promote team building and encourage a more cooperative work environment. Aside from health outcomes, the program sends a message to the employees that health and wellness are priorities for the agency. 6.4.9 Participation Metrics Participation in several of the activities increased from 2017, the programâs first year, to 2018. For example, participants in the corporate games event rose from 25 in 2017 to 43 in 2018, a significant increase. Data from TARCâs health insurance provider also showed a growing level of involvement since the beginning of the transit agencyâs wellness program. Participants are given points for reaching certain levels under the âHumana Goâ program (blue, bronze, silver, gold, and platinum). Total participation increased from 84% of all health insurance subscribers (not including dependents and spouses) in 2016 to 94% in 2018. 6.4.10 Workforce Characteristics A total of 338 frontline operators and maintenance workers were employed in 2015 (at the time the program was introduced). Following the programâs rollout in 2016, of these 338 workers 13 employees had attended boot camps, 49 employees had a âhighâ Humana Go level (i.e., bronze, silver, gold, or platinum level), and 54 employees had attended a bio screening.

72 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line The project team selected these participation variables for analysis because they had the highest participation numbers of the numerous activities included in TARCâs health program. Table 38 presents demographic characteristics for both the total population of TARCâs frontline employees and for the agencyâs operators and maintenance employees in 2015. As seen in Table 38, the White population was slightly older than the African-American population. The average age for the 108 White workers was 54.1 years, compared with 51.1 years for the 230 African-American workers. Men were slightly older than women, with an average age of 53.7 years for men compared with 49.8 years for women. The table replicates the pattern observed at IndyGo and RTS, where the majority of the maintenance workers were male. The project team used the data from TARC to further examine how outcomes related to absenteeism were related to participation in the program. To be counted, the workforce under observation in the two analyses performed had to have been employed with TARC since 2015, and their employment had to include at least 1 full calendar year during the period 2016â2017. In this case, multiple measures of participation (key independent variables) were used, and analysis was conducted to see if each one individually was associated with a change in absenteeism. Each category of participation was represented by groups with characteristics, as displayed in Table 39. As shown in Table 39, 13 employees participated in boot camps; these participants had a younger average age (45.3 years) compared to the non-participants (52.3 years). Forty-six employees had an elevated (silver-level or gold-level) Humana Go participation status, and Table 38. Demographics of TARC frontline population, 2015. Demographic Characteristic Operator Maintenance All Employees Count Percent Age * Count Percent Age * Count Percent Age * African American 228 80.6% 51.2 2 3.6% 44.0 230 68.0% 51.1 White 55 19.4% 55.6 53 96.4% 52.6 108 32.0% 54.1 Female 135 47.7% 49.8 1 1.8% 54.0 136 40.2% 49.8 Male 148 52.3% 54.1 54 98.2% 52.2 202 59.8% 53.7 Total 283 100.0% 56.8 55 100.0% 55.6 338 100.0% 56.5 * All ages are averages. Table 39. Program participation and age of TARC frontline population, 2016â2017. Program Participation Operator Maintenance All Count Percent Age * Count Percent Age * Count Percent Age * Key independent variable: participation in boot camps Participated in boot camps 4 1.4% 45.3 9 16.4% 52.4 13 3.8% 50.2 Key independent variable: elevated (gold, silver, or platinum) Humana Go status Base Humana Go status 245 86.6% 52.8 47 85.5% 52.8 292 86.4% 52.8 Elevated Humana Go status 38 13.4% 48.4 8 14.5% 51.8 46 13.6% 48.4 Key independent variable: attended bioscreen Did not attend bioscreen 241 85.2% 52.4 45 81.8% 52.7 286 84.6% 52.5 Attended bioscreen 42 14.8% 50.9 10 18.2% 52.3 52 15.4% 50.9 Total 283 100.00% 52.2 55 100.00% 52.6 338 100.00% 52.5 * All ages are averages.

Case Studies: Health Promotion Programs 73 these participants were younger on average (48.4 years) compared to employees who had a base (blue) level of participation (52.8 years). Fifty-two employees participated in bioscreens, and again had a younger average age (50.9 years) than employees who did not participate (52.5 years). In general, the employees who participated in the wellness program activities tended to be younger than those who did not participate. The Humana Go program was sponsored by the insurer. Employees received points for their participation in wellness program activities, including bioscreens. The points were added up to reach defined levels under the Humana Go program, progressing from blue (the base level) through bronze, silver, and gold, to platinum (the highest level). As an incentive to participation, employees also could earn prizes based on the points they accumulated (partici- pation level). 6.4.11 The Program Over Time Figure 12 presents the average annual number of absentee hours for frontline employees over the 4 years from 2015 through 2018. This analysis used 2015 as the baseline year because the comprehensive wellness program began in 2016. Only one pre-program data point was available, so the data shown in Figure 12 should be interpreted cautiously. Absenteeism days were defined as total hours of sick leave, personal leave, and unpaid leave. As the figure shows, the total average annual absentee hours increased from about 45 hours in 2015 to about 60 hours in 2018. It further shows that women had higher rates of absenteeism, which also was seen in other case studies. Figure 13 presents the average number of annual absentee hours for TARC operators and maintenance workers over the same period, compared to the averages for all frontline employees (Grand Total). As seen in Figure 13, operators consistently had a higher average of total annual absentee hours than did maintenance workers. Again, for all frontline workers, the average annual total absentee hours ranged from about 45 hours in 2015 to about 60 hours in 2018. 6.4.12 Workersâ Compensation Table 40 shows the number of indemnity claims by year from 2015â2017, with partial-year information from 2018 (the 4 years provided by the agency). It was not possible to associate claims with the individual/participant in the health claims, so a regression analysis examining the relationship between changes in claims and participation was not conducted. Figure 12. Average annual total absentee hours, TARC frontline employees, 2015â2018. 0 10 20 30 40 50 60 70 80 90 2015 2016 2017 2018 Black or African American White Female Male Grand Total

74 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line Table 40 demonstrates a trend commonly seen across the case studies, which was that indemnity claims were variable and subject to fluctuation due to factors such as a few high claims. In the case of TARC indemnity claims, the table also shows that the number of unique claims is not much higher than the number of employees with claims, indicating that the instance of repeat claimants was not large. 6.4.13 Results Many variations of the linear regression were performed. The project team varied the dependent variable, changed the mix of the independent variables, and tried several interaction terms of program participation (e.g., boot camp participation or Humana Go level interacted with various demographic variables). In no case was the coefficient on the effect of program participation significantly different from zero, and in no case did participation have a statis- tically significant effect on health (here measured as the change in days absent). Appendix C presents the results of the linear regression analysis, and within the appendix Tables C-4 (Humana Go), C-5 (boot camp), and C-6 (bioscreens) present representative regression results of the various models. 6.5 DART This case study was developed with the input of the human resources manager and chief human resources officer for DART, and the president and business agent of ATU Local 441. 0 10 20 30 40 50 60 70 80 90 2015 2016 2017 2018 Operator Maintenance Grand Total Figure 13. Comparing average annual total absentee hours for TARC operators, maintenance workers, and all TARC frontline workers, 2015â2018. Table 40. Workersâ compensation indemnity claims by year, TARC, 2015â2017 and part of 2018. Year Sum of Claims Unique Claims Average Cost per Claim Employees With Claims 2015 $498,767 63 $7,917 58 2016 $458,357 63 $7,276 60 2017 $1,033,219 76 $13,595 69 2018, JanuaryâMay $260,673 36 $7,241 35 Total $2,251,016 238 $9,458 222

Case Studies: Health Promotion Programs 75 6.5.1 Background DART is the first regional transit authority in Iowa created under state legislation and was approved in 2005. The agency operates the largest transit system in Iowa, providing more than 15,000 trips per day with a fleet of approximately 145 buses. DART is expanding throughout its service area, introducing more express, shuttle, and weekend service hours. DART also has one of the largest vanpool programs in the Midwest, with more than 100 vans (Iowa DOT n.d.). More than 280 individuals are employed at DART, including its fixed-route and paratransit operators, maintenance and facilities staff, and administration (DART n.d.-b). Taking advantage of a change in leadership within both the labor union and the transit agency management, DART has worked to encourage employees to enroll in the existing health savings account plan and make lifestyle changes. In 2017, DART implemented a comprehensive wellness program for all employees. 6.5.2 Program Startup and Development DARTâs annual wellness program began in October 2017. Before developing this program, the agencyâs only targeted wellness-related activities were biometric screenings and health risk assessments (HRAs) (McMahon, personal communication, 2018). These programs started 2 years before the current wellness program. DART has promoted a rigorous safety program since 2007 and was recognized by APTA in 2011 for its achievements in building a strong safety cul- ture (DART 2011). The development of the wellness program indicates a shift toward a more holistic approach to the health and safety of its employees. The wellness program was begun for several reasons, including a high number of workersâ compensation claims, low morale, and low employee engagement, and to boost awareness of and participation in the existing wellness screening program and HRAs (McMahon, personal communication, 2018). To structure the program to best suit the needs of the employees, a wellness interest survey was given to employees before the program inception. Ninety percent of employees parti- cipated in the survey; the program was designed and budgeted based on their responses (McMahon, personal communication). A total of 201 survey responses (182 complete, 19 partial) were received in which employees identified desired topics, the length of activities, and most convenient times of the day for activities to take place (McMahon, personal communication). 6.5.3 Work Organization/Work Environment The union has worked with management to improve shifts for operators and therefore reduce the impacts of difficult working hours. The majority (53%) of operators work split shifts, arriving at 5:00 a.m. and working until 8:00 a.m. or 9:00 a.m., after which they break until 2:00, then work again until 6:00 p.m. Efforts have been made to reduce the length of the break between shifts. The union has been bargaining for better scheduling and has worked with management on this issue because it helps with worker retention. Maintenance workers have more standard shifts, working 8-hour or 10-hour shifts with a break scheduled midway during the shift. Restroom access for operators has been a longstanding issue. Management adjusted operator routes due to complaints of urinary tract infections caused by not being able to use the rest- room when needed. Recovery time is now spent at the station, so operators have access to the restroom there. Another issue for operators is proper positioning and type of seat. In 2016, DART bought new seats for their buses and allowed operators to choose the model. The agency also redesigned DART Program Elements â¢ Monthly topics incorporated into the wellness program: back care, cold/flu prevention, diabetes, financial wellness, healthy cooking/ eating, heart health, physical activity, sleep management, stress management, and weight management; â¢ All topics chosen based on survey responses indicating employee interests; â¢ Two to three workshops per month (at DART); â¢ One to three wellness challenges per month that focus on making lifestyle changes (outside of DART); â¢ UnityPoint available at main campus or Central Station location once per month for coaching in operator lounge; and â¢ Gifts/prizes based on participation. DART Survey Response: How Long Should Wellness Activities Last? Most employees believe activities should last between 30â60 minutes, depending on the activity. Averaged across all activities, 41.1% of respondents indicated that activities should last 30 minutes; 20.0% of respondents indicated they should last 45 minutes, and 22.9% of respondents indicated they should last 60 minutes.

76 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line the wheelchair securement stations so that they require less bending and stooping and allow more room to maneuver (reducing lower back pain). When operators have specific complaints about the seat, they are addressed. Often this is done by readjusting the seat or teaching the operator how to do so. The agency also implemented job offer testing to make sure that opera- tors are physically able to do all functional aspects of the position. Approximately 65%â70% of all frontline employees participate in the agencyâs health insurance plan. DART requires an annual bioscreening for every employee enrolled in the health insurance plan. 6.5.4 Health, Wellness, and Safety Concerns The union stated that the most prevalent health concerns among its members were chronic pain from the demands of the job (e.g., back pain, injuries resulting from repetitive motion); high blood pressure; and metabolic disease (e.g., diabetes). The agency had a slightly different perception of the top health and safety issues, stating that the top three were weight management, cardiovascular health, and effects of the job (e.g., ergonomics/fatigue/stress management). The agency stated that their rates of medical disqualification among operators were low, but among those that had been disqualified, the primary reasons were diabetes and soft-tissue injuries, usually occurring in the shoulder due to repetitive movement. 6.5.5 Program Activities/Elements According to DART, the program does not focus on any one aspect of health and wellness but rather on caring for the whole person. To that end, the program is multifaceted, incorporating many different topics and methods of approach. DART has engaged insurance providers, financial planners, and registered nurses to deliver workshops and provide coaching and advice to participants (McMahon, personal communication, 2018). A monthly theme is chosen that corresponds with the interests recorded by employees in the initial survey. To complement the theme, two to three monthly workshops are given at DART, as well as one to three wellness challenges that encourage participants to make lifestyle changes. Participation is incentivized with gifts and prizes ranging from sports equipment to gift certificates. Rewards are given for attending workshops and completing the monthly wellness challenges. Participants receive a reward based on the tier they have reached at the end of the program: Tier 1 is reached by attending three workshops and completing three challenges; Tier 2 is reached by attending six workshops and completing six challenges; and Tier 3 is reached by those who attend all workshops and complete all challenges (McMahon, personal communication, 2018). Outside of the events organized as part of the program, the agency has implemented several policies to improve the work environment. DART has created a new vending program so that fruit, vegetables, eggs, and protein bars are available instead of the more common snacks found in vending machines. The agency also hired specialists to analyze the buses and create cards illustrating the stretches appropriate for operators and their environment. Frontline employees are not paid for the time they spend at wellness events. This has caused some reluctance among operators and maintainers to attend events. Administrative employees attend the events during their workday, and are therefore being paid for their time. 6.5.6 Organization The wellness program relies on the planning and support of a seven-member wellness committee. Positions are open to all departments within DART. The committee meets every month to prepare for the following month and make changes and adjustments to the program as needed. Currently, the committee is staffed by the human resources manager, an operations DART Survey Response: Topics of Interest â¢ Back care, â¢ Cold/flu prevention, â¢ Diabetes, â¢ Financial wellness, â¢ Healthy cooking/eating, â¢ Heart health, â¢ Physical activity, â¢ Sleep management, â¢ Stress management, â¢ Weight management, â¢ Menâs and womenâs health, and â¢ Understanding medical insurance and other benefits offered at DART. DART Wellness Committee â¢ Seven members, â¢ Committee members from all departments, and â¢ Monthly meeting to prepare for next month and make changes/ adjustments.

Case Studies: Health Promotion Programs 77 instructor, two fixed-route operators, a maintenance employee, an operations supervisor, and a transit planner (McMahon, personal communication, 2018). The wellness committee and the program have the support and participation of the local union thanks in part to the member- ship of its president, a fixed-route operator, on the wellness committee (McMahon, personal communication, 2018). 6.5.7 Resources DARTâs wellness program has a relatively low budget (approximately $5,000 annually) and has relied on existing staff to manage the program rather than hiring dedicated staff. For 2017, approximately half of the budget was used for workshops and the other half for the purchasing of incentives. No additional major capital expenditures have been made. Instead, DART has used existing resources to provide programming. Several workshops have been provided at no cost to DART through leveraging connections with wellness organizations and professionals. 6.5.8 Qualitative Program Benefits Behavioral and cultural shifts have occurred both within the management of DART and within the employee community. A new leadership approach, brought about by a transition in management positions, has been instrumental in changing the environment and focus of the agency. DART appointed a new chief operating officer in October 2015 and a new chief human resources officer in December 2016 (DART n.d.-a). Within the employee community, the inclusion of influential individuals on the wellness committee has been an important component to foster a sense of ownership of the program. There is a focus on the personal participation and commitment to life changes of the committee members. The administration has taken the feedback received at the monthly wellness committee meetings and used it to structure the program and increased the budget for next year of the program based on the input of the wellness committee (McMahon, personal communication, 2018). Participation in the HRA was approximately 20% before the start of the wellness program because of workforce resistance to the biometrics screening, which was a requirement for being enrolled in the agency health insurance plan. Following the start of the program in October 2017, 100% of the agencyâs employees participated in the subsequent HRA, which occurred the next month. DART recognized that a lack of clarity about whether the HRA was a required part of the bioscreening contributed to the initially low participation rate. Among the employees, some fear also had existed about what the results of the HRA would be used for. The start of the wellness program prompted more discussion with union leadership and with the employees in general, which led to a shift in perception and an increase in engagement, which was the most important and effective change (McMahon, personal communication, 2018). Despite these successes, management acknowledges that other elements of the wellness program have not reached all employees. Although events were held at different times of day and days of the week in an attempt to boost participation, scheduling remained an issue. The employees who did attend came to many of the events. The small percentage of employees who were very active in the program got the most benefit. From the perspective of the union, the program was beneficial in raising awareness of health issues and there was a general sentiment that it was a good idea. Most employees lacked a will- ingness to participate long-term in the program, however. Frontline employees were asked to attend program events in their free time while administrative employees were often on the clock during events; this created some resentment among frontline employees and exacerbated

78 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line problems of participation. Participation increased when incentives were offered, but the effect of the incentives dwindled over time. Issues related to participation were difficult to address given the varying shifts of frontline workers, particularly operators. The types of shifts that employees worked had an impact on how they engaged with the wellness program. Operators were more likely to participate in the scheduled events (presumably because these events fit into their breaks between shifts), whereas maintainers/mechanics used the onsite gym at a higher rate. After running for 9 months, the wellness program discontinued. Due to several agency staff members leaving who had been instrumental in the vision for the program, the committee was dissolved and no more regular events were scheduled. 6.5.9 Reported Metrics Participation data were collected and recorded for each event (McMahon, personal commu- nication, 2018). The goal for participation in the first year of the wellness program was 30% of employees. Actual participation, measured as having attended at least one activity/workshop, was around 42% of employees. Participation in the HRA and biometrics screenings increased from 20% before the start of the program to 100% in the month following the start of the program (McMahon, personal communication, 2018). Although the program was too brief to be able to measure changes in other metrics, such as workersâ compensation claims and absenteeism, program staff has continued to collect data to help assess the effectiveness of the program. 6.5.10 Workforce Characteristics A total of 245 frontline workers (operators and maintenance) were employed with DART at the beginning of 2016, a year before the program started in 2017. Table 41 presents demo- graphic information for the total population of frontline employees and separate break downs for the operators and maintenance employees. Unlike the other case studies, information on age at the individual level was not provided by DART. Compared to some populations in the other case studies, a larger share of this workforce (84.9%) was male. As in the other agencies, the majority of maintenance workers were male. The analysis method was to examine if and how outcomes related to absenteeism were related to participation in the program. Thus, the analysis divided the population of frontline employees into two groups: those who were recorded as having participated in at least one activity Demographic Characteristic * Operator Maintenance All Count Percent Count Percent Count Percent Asian 9 4.4% 3 7.1% 12 4.9% African American 64 31.5% 13 31.0% 77 31.4% Hispanic or Latino 14 6.9% 8 19.1% 22 9.0% Two or more races 1 0.5% 1 2.4% 2 0.8% White 115 56.7% 17 40.5% 132 53.9% Female 36 17.7% 1 2.4% 37 15.1% Male 167 82.3% 41 97.6% 208 84.9% All 203 100.0% 42 100.0% 245 100.0% * Age-related information at the individual level was unavailable for this case study. Table 41. Demographics of DART frontline population, 2016.

Case Studies: Health Promotion Programs 79 and those who were recorded as having participated in no activities. The characteristics of these two groups are displayed in Table 42. The activities included a series of workshops and wellness challenges. As Table 42 demonstrates, 16 employees (out of a total of 245) were recorded by human resources as having participated in at least one activity. Many of the individuals who participated in at least one activity participated in multiple activities. This analysis did not account for marginal gains associated with participation in multiple activities. 6.5.11 The Program Over Time Figure 14 presents the average number of annual absentee hours for DART frontline employees for a 3-year period (2016â2018). Absenteeism hours were defined based on total hours of sick leave, personal leave, and unpaid leave. Figures 14, 15, 16, and 17 show absentee days over time by demographic characteristics and by job classification. A full year of information was not available for 2018, so for 2018 the full year was estimated by comparing the available months with the previous year and assuming that the difference in hours remained the same between the first and last six months of 2017 and 2018. Figure 15 presents the median annual absentee hours for race and sex. Figure 16 presents the average annual absentee hours for DART frontline employees divided by job type over the same 3-year period (2016â2018). Figure 17 presents the absentee hours over time for all employees and those that participated or did not participate in any activities. On average, employees who participated in any activities Program Participation Operator Maintenance AllCount Percent Count Percent Count Percent Did not participate 191 94.1% 38 90.5% 229 93.5% Participated in at least one activity 12 5.9% 4 9.5% 16 6.5% All 203 100.0% 42 100.0% 245 100.0% Table 42. Program participation of DART frontline population, 2016. 0 50 100 150 200 2016 2017 2018 White Female Hispanic or Latino Male Black or African American Other Grand Total Figure 14. Average annual total absentee hours of DART frontline employees by demographic characteristics, 2016â2018.

80 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line Figure 15. Median annual total absentee hours of DART frontline employees by race and sex, 2016â2018. 0 20 40 60 80 100 120 140 160 2016 2017 2018 Black or African American White Female Male Grand Total Figure 16. Average annual total absentee hours of DART frontline employees by job classification, 2016â2018. 0 20 40 60 80 100 120 140 160 180 2016 2017 2018 Maintenance Operator Grand Total Figure 17. Total absentee hours, DART frontline employees, 2016â2018. 0 20 40 60 80 100 120 140 2016 2017 2018 No Participation Participated in Activities Grand Total

Case Studies: Health Promotion Programs 81 used fewer sick days than did non-participating employees; however, because only 16 employees are recorded as participating in any activities, this is probably a case of self-selection bias. 6.5.12 Results A set of 115 observations were available to test for whether program participation had an effect on health. The principal regression model was used to examine the relationship between program participation and absentee hours (see Table 43). The model included controls for race, gender, and type of employee (mechanic or operator). The coefficient estimate of â3.9 was statistically significant at the 95% confidence level. Thus, the project team estimated parti cipation in the program resulted in a 4-hour decrease in absentee hours. Further, race was found to be statistically significant at the 95% confidence level. Specifically, if an employee was White, then absentee hours decreased by 16 hours. No other variable was statistically significant. Because the sample of workers was smallâonly 12 operators and 4 mechanics participated in at least one activityâthe results may be meaningful, but should be interpreted with caution. The results from this model demonstrate that it is possible to find an impact of a wellness program on one of the measures (absentee hours) that often is available at transit agencies. Other agencies may be able to use this approach to evaluate the effectiveness of their wellness programs. 6.6 LA Metro This case study was developed through emails and discussions with the International Union of Sheet, Metal, Air, Rail and Transportation Workers (SMART)âMetropolitan Transportation Authority (MTA) wellness manager and the vice-general chairman of SMART Local 1565. 6.6.1 Background LA Metro serves the 9.6 million residents of Los Angeles County, California, with 165 bus routes and a fleet of 2,308 buses alongside four light rail and two subway lines. Bus and rail operators at LA Metro totaled 4,397 employees in 2018. These occupations were represented by the United Transportation Union (UTU) until 2008, when the UTU merged with SMART. LA Metro also employs 2,370 mechanics, who are represented by the ATU. There are 9,817 total full-time employees at LA Metro. Together, SMART and the MTA manage a trust fund that administers benefits for bus and light rail operators. Ordinary Least Squares: Change in Hours Estimate t-Stat Intercept 38.0 3.60 Participation -3.9 -2.13 Male -5.9 -0.55 White -16.2 -2.32 Mechanic -3.5 -0.40 Observations 115.0 -- R2 0.078 -- Adjusted R2 0.046 -- Table 43. Effect of program participation on absentee hours, DART frontline employees, 2016â2017.

82 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line 6.6.2 Program Startup and Development In 2006, LA Metro piloted a health and wellness pilot program at two locations. The agency started the pilot to produce positive effects on absenteeism and workersâ compensation claims. At the end of the pilot program in 2009, LA Metro determined that it did not have the resources to continue to fund the program long-term; however, the value of the program had been recognized and the SMART-MTA trust fund stepped in to manage a permanent program. The program was expanded to 24 locations, including all of the main facilities. 6.6.3 Work Organization/Work Environment Currently, almost 50% of operators work split shifts, with the remainder split evenly between operators who work three shifts and those who work more traditional hours. Because of the demands of their schedules, fatigue can be an issue preventing operators from attending wellness program events. This type of schedule also can be seen as a benefit, however, because operators can use their breaks between shifts as an opportunity to rest, exercise, and/or participate in wellness activities. Since 2017, SMART has worked with the University of California, Irvine, to assess the workplace and job tasks that positively and negatively impact employeesâ health and behaviors. The health program plans to use the findings from the university assessment to create program- ming to improve the overall health of employees and their families. The close attention to employees has helped uncover issues that can be resolved by influencing positive changes in corporate culture, policies, and procedures at LA Metro (e.g., schedule changes). 6.6.4 Health, Wellness, and Safety Concerns According to the SMART-MTA Wellness Program Strategic Plan 2018â2020, diabetes, hyper- tension, and cancer are targeted for disease management programs. The vice-general chairman at SMART cited diabetes, high blood pressure/hypertension, and stress as the top three health and safety issues with which the union and its members are most concerned. He shared that stress contributes to many of the health issues that operators suffer from, such as heart condi- tions and sleep apnea, which are causes for medical disqualification of operators, though the instances are low (Wormley, personal communication, 2019). 6.6.5 Program Activities/Elements The primary focus of the health and wellness program is to assist operators, but all employees, regardless of union affiliation, can participate. One program feature cited by the agency and union as leading to its success is the use of ambassadors. Ambassadors are selected from among the frontline workers to promote the wellness program. Each location has an ambassador, and large locations may have multiple ambassadors. Most locations have two wellness ambassadors from SMART (usually a main and an alternate). On specified days (called Wellness Wednesdays), the wellness ambassadors are given 8 hours of release time to engage employees in program activities. Ambassadors also are given hours of release time for offsite events, which are primarily weekend events. Compensation for ambassadorsâ time spent on wellness program duties is covered by the MTA. LA Metroâs wellness program runs year-round and features disease management and edu- cation, seminars and table topics, fitness challenges, health fairs and screenings, free family sporting events, and a monthly wellness newsletter. Each year, eight health fairs are held at different facilities on a rotating schedule with the result that over 3 years, all locations hold a

Case Studies: Health Promotion Programs 83 health fair. Wellness activities occur mainly on Wednesdays and are scheduled to coincide with operator breaks between split shifts. The wellness program also has an incentivized weight loss program, called the Metrofit Club. The program is optional and requires a commitment of 10â12 weeks. Participants weigh in every other week with their wellness ambassador and receive assistance in their efforts through education on calculating caloric intake, recipe preparation, and basic nutrition. The program is incentivized with monetary rewards of up to $100 for losing a certain percentage of body weight. A concerted effort has been made to promote LA Metroâs wellness program. This has been done in several ways, including the presence of wellness ambassadors; union, employer, and health plan communication channels; incentives, rewards, kickoff events, challenges, and contests; a consistent theme and key messages; and mail, posters, email, newsletters, and social media marketing and testimonials. 6.6.6 Program Organization The health and wellness program is managed by a full-time coordinator. A health and wellness committee also provides input on programming and goals. The committee meets quarterly, is chaired by the wellness coordinator, and is represented equally by staff and labor members, though two unions working with LA Metro are not represented on the committee (the ATU and the Teamsters Union, which represents security guards). SMART is working toward a goal of including the Teamsters Union and the ATU on the committee, representing mechanics. Ambassadors are chosen jointly by union leadership and management. Every January, the ambassador roles and responsibilities are reviewed, and ambassadors are asked if they want to renew their contract. Training for new ambassadors occurs every quarter. 6.6.7 Program Resources Program costs, not including ambassador pay and the salary of the wellness program manager, amount to approximately $55,000 annually. Health insurance providers contribute to the budget as part of the services offered to employees in exchange for premiums; however, the insur- ance provider does not control the program fund itself. A union trust fund covers the ambas- sador pay (about $275,000 annually) and also covers the salary of the wellness program manager. 6.6.8 Qualitative Program Benefits The project teamâs analysis indicated that the pilot program produced benefits. Injury- related claims decreased at some locations, and employees reported better sleep, weight loss, and reduced stress. Participation was tracked by employee badge number and showed that 382 employees participated in some element of the program during the pilot. Since 2009, the expanded program has seen increased levels of participation. Between 2009 and 2012, long-term goals of the program were to reach 10% partici pation and limit health insurance premium rate increases to no more than 5%. Increased partici- pation in the expanded program meant that more employees accessed services covered by the health insurance provider, which led to higher premium rates. Although the increased participation was a positive step, it negatively impacted the premium; for this reason, the well- ness committee changed the goal respecting premiums to maintaining a cost âless than the Southern California healthcare trends.â Program Promotion â¢ Wellness ambassadors; â¢ Use of all communication channels (union, employer, and health plan); â¢ Incentives, rewards, kick-off events, challenges, and contests; â¢ Consistent theme, key messages; and â¢ Mail, posters, email, newsletters, social media, and testimonials.

84 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line SMART uses program data from its health insurance provider to tailor the program and counter cost trends. For example, high numbers of emergency room (ER) visits led to program education on how to avoid using the ER by scheduling appointments and going first to primary care. Results from biometrics screenings performed at the health fairs and data from LA Metro on employee metrics also are used to inform programmatic elements. Results are communicated in a newsletter for members with highlights of the changes in different measures. The program has resulted in policy changes that signify management and union willingness to work together toward the health of employees and ensure that the program receives the proper support and attention. When the program first started and the concept of well- ness ambassadors was introduced, management at LA Metro agreed to provide time off for the ambassadorsâ participation in Wellness Wednesday activities. As the program progressed, wellness ambassadors were given paid time for Wellness Wednesdays, and eventually were given paid time off for events outside of work hours, including weekend events. This shift has raised the status of wellness ambassadors and the program generally. According to the program coordinator, the employeesâ attitudes toward the program have changed from indifference to more overtly positive sentiments. Employees actively seek out elements of the program and are more willing to provide their success stories, which are published in the wellness newsletter. Union leadership expressed the view that members are genuinely excited about the program and appreciate the involvement of the union and management because it shows that both the union and management have taken a concern in the operatorsâ health. 6.6.9 Reported Metrics For this analysis, participation was defined as a person attending at least one event within a year. From 2012 through 2017, participation data from LA Metro showed generally positive trends, rising to 38% by 2014 and remaining close to that percentage in later years (Figure 18). Through the Metrofit Club, SMART has tracked the weight loss of participating employees. Figure 19 shows a peak in pounds lost in 2014, after which the amount of weight lost declined in 2015 and 2016. The drop-off may not be a negative trend, however, as the amount of weight lost in 2014 might mean that many participants had already reached or were approaching a healthy weight. Figure 20 shows the number of health club participants per year. The peak was in 2014 at 584 participants. There was a drop-off in 2016, but a slight increase in 2017 brought the number 38%37%38%38% 33% 28% 0% 5% 10% 15% 20% 25% 30% 35% 40% 201720162015201420132012 Figure 18. Participation in health program as a percentage of total LA Metro employee population, 2012â2017.

Case Studies: Health Promotion Programs 85 of participants back up to 446. The pattern seems to be fairly stable and all other years were higher than the initial year of 2012. Data from LA Metro was only provided in the aggregate, so the project team was unable to conduct regression modeling as was done with the other case studies. The information learned from this case study was based on LA Metroâs reports of employee participation in the activities and the overall weight lost by employees, but could not be correlated with outcomes such as absenteeism or controlled for race, gender, or type of position. 6.7 Summary of Case Studies The work organization and environment at each case study location was unique, and each agency faced different health, wellness, and safety challenges. Many commonalities were found across the locations, however: For example, at all five locations, the majority of bus operators worked split shifts, and some operators worked irregular schedules. The varied scheduling patterns impacted operatorsâ access to healthy food and their sleep patterns, and limited their ability to participate in certain health and wellness program activities. 6.7.1 Program Development and Work Environment The health and wellness programs examined were developed for various reasons and to meet various needs. For example, IndyGo added an onsite clinic as a way to avoid steep insurance premium increases. RTS began with a focus on physical fitness, but added more goals after several years, eventually hiring a full-time health and wellness coordinator. TARCâs 1,500 1,345 1,580 2,039 1,799 1,162 0 500 1000 1500 2000 2500 201720162015201420132012 Po un ds Figure 19. Weight lost per year (in pounds), Metrofit Club participants, 2012â2017. 446420 537 584564 305 0 100 200 300 400 500 600 700 201720162015201420132012 Figure 20. Number of Metrofit Club participants per year, 2012â2017.

86 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line initial focus was on smoking cessation, but the program was expanded to include more general wellness goals. DART encouraged employees to take advantage of all existing employee benefit programs, including a health savings account, and implemented a comprehensive wellness program for all employees. LA Metroâs program began as a pilot in two locations and expanded to 24 locations. At all the sites, at least half of the operators worked split shifts. This presented some chal- lenges for staff, including accessing healthy food choices and finding time for regular exercise. Irregular shifts also contributed to sleep deprivation. An issue emphasized at most sites by staff and union representatives was restroom access. 6.7.2 Health, Wellness, and Safety Concerns Comparing the top three health, wellness, and safety concerns expressed by management and labor representatives and examining insurance claims data, the project team found hyper- tension, musculoskeletal injuries (back and neck pain), and diabetes to be the most commonly found concerns for frontline transit workers across the locations (Table 44). Other areas of concern included sleep apnea, cardiovascular diseases (heart conditions), injuries from bus accidents, obesity, stress/fatigue, and cholesterol disorders (hyperlipidemia). Table 44 lists the top three health issues for each of the health and wellness programs discussed in the case studies and breaks down each issue by three sources: management, labor, and claims data. Not all locations provided data from all three sources. In several cases, management used analysis from insurance claims data to respond to the question about their top health, wellness, and safety concerns. At all five case study locations, labor listed diabetes as a major concernâindeed, in two of the five locations, it was the top concern. Hypertension also was named by labor in four of the five agency locations. Claims data added obesity (including hyperlipidemia) and back pain to the list of top health issues. Management, on the other hand, was more concerned with musculoskeletal injuries, weight management/cardiovascular health, and vehicular accidents. Figure 21 graphs the information presented in Table 44. Again, the most commonly mentioned issue was hypertension, followed by diabetes and musculoskeletal injuries. Areas with only one mention were included in the âOtherâ category. The distribution of concerns in Figure 21 Program Constituent Priority of Health/Safety Concern Primary Secondary Tertiary IndyGo Management Musculoskeletal injuries Slips, trips, and falls Vehicle accidents Labor Diabetes Sleep apnea Hypertension Claims data Obesity Hypertension Diabetes RTS Labor Sleep apnea Diabetes HypertensionClaims data Hypertension Cholesterol disorders Back and neck problems TARC Labor Operator assault Operator injury from accidents Breathing in harmful fumes Claims data Hypertension Hyperlipidemia Back pain DART Management Weight management Cardiovascular health Ergonomics/fatigue/stress management Labor Chronic pain from the job Hypertension Metabolic disease (e.g., diabetes) LA Metro Joint trust fund Diabetes Hypertension CancerLabor Diabetes Hypertension Stress Table 44. Comparison of top three health, wellness, and safety concerns at five case study locations.

Case Studies: Health Promotion Programs 87 broadly follows the data presented in Chapter 4 regarding the most prevalent health and safety issues for transit workers, with other key conditions also represented. Given the variations in data-supported or perceived health and wellness concerns, program design elements such as activities offered, facility needs, incentives for participation, staffing, organization of committees, and selection of champions were distinct from location to location. Chapter 7 presents process-driven strategies based on these case studies that transit systems can use to maximize program effectiveness. 6.7.3 Program Activities and Elements The programs offered various voluntary activities to employees, though it was common to provide incentives for participation. At IndyGo, participants were required to undergo a physical, health assessment, biometric screening, a minimum of four coaching sessions, and participate in a health activity to qualify for an insurance discount. Health activities might include gardening, Weight Watchers, exercise classes, walkârun groups, 5Ks, basketball tournaments, and/or financial or nutrition classes. RTS offered short workshops onsite, fresh fruit, team activities, different choices in their vending machines, blood pressure kiosks, health screenings, and a wellness center that includes a gym. TARCâs program began with a focus on smoking cessation but later expanded to provide events and programs organized around themes of interest, an annual corporate games week- end, and a fitness-oriented boot camp. The agency has offered some incentives and prizes to participants, but nothing systematic. TARC has provided its employees access to two onsite fitness centers, where they can participate in weekly yoga classes, 5K runs and participant preparation assistance, periodic weight loss/weight maintenance challenges, walking events, and bioscreens. Figure 21. Most common health, wellness, and safety concerns at five case study locations.

88 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line DARTâs program did not focus on any one aspect of health and wellness but had a different theme each month that corresponds with the interests recorded by employees in the initial survey. DART has offered two to three workshops and one to three wellness challenges every month. Rewards were given for attending workshops. LA Metro has used wellness ambassadors and provided incentives, rewards, kickoff events, challenges, and contests. The wellness program featured disease management and education, seminars and table topics, fitness challenges, health fairs and screenings, free family sporting events, and a monthly wellness newsletter. Following a rotating schedule, eight annual fairs were held at different facilities so that, over 3 years, all locations had held a health fair. Wellness activities were scheduled to coincide with operator breaks between split shifts. The wellness program also had an incentivized weight loss program. 6.7.4 Organization Most programs were overseen by human resources departments and used third-party vendors to provide services. Several programs had full-time coordinators and volunteers (or paid employees) who served as wellness âcoordinatorsâ or âambassadors.â The funding came from a mix of operating budgets, and agencies were able to detail staff who were already employed with the agency to serve the programs. All the sites examined had a wellness committee that was staffed with a mix of management, union representatives, and frontline staff. Committees met regularly and helped determine the activities and goals of the programs. These programs worked best when there was a cooperative relationship between management and the union. The programs demonstrated a wide range of budgets and operating processes. The best-funded of the case studies was IndyGo, which staffed a clinic with two nurse practitioners, a part-time doctor, and medical assistants. During the assessed period, IndyGo operated with a budget of $500,000 per year. RTS employed one full-time wellness coordinator and funded the program through the agencyâs operating budget, using third-party vendors, spending approximately $41,000 per year. TARCâs program was funded by the agencyâs human resources office with a budget of approximately $10,000 per year, though the program received additional funds via a premium refund from their health insurance carrier. DART had a relatively low budget of approximately $5,000 annually. Dart relied on existing staff members to manage the program rather than hiring dedicated personnel. Finally, LA Metro spent approximately $55,000 annually, not including the salary for the program coordinator. The health insurance provider contributed to the program budget through a negotiated premium arrangement, though the fund itself was not controlled by the health insurance provider. A union trust fund covered the ambassadorsâ pay and the salary of the wellness program manager. 6.7.5 Workforce Characteristics Overall, a racial and gender divide was evident based on job roles. The majority of operators were male, but some gender diversity could be found, with one site having a male population of âonlyâ 52.3% (see Table 45). Maintenance workers were overwhelmingly male, with no site lower than 93%. At all sites, at least three-quarters of maintenance employees were White. The demographics of the populations that are eligible or participate in the wellness programs can help agencies decide on how to focus their activities and how to market them effectively. Figure 22 shows the annual total average absentee hours for each of the case study sites. A great deal of variability can be seen across the agencies, which leads to the conclusion that each must be considered in a local context. Absenteeism seems to be a much greater issue in

Case Studies: Health Promotion Programs 89 some places than others: DART, in particular, experienced such high rates that it is possible to suspect some data discrepancy may explain it, though our discussions with the agency did not suggest this. IndyGo experienced a fairly steady rise in absenteeism beginning in 2014, which might be attributable to a structural change. RTS and TARC have more level numbers, but also seem to have experienced slight rises in absentee hours. This issue is one that agencies will want to continue to monitor. Although absenteeism seems like a good outcome variable for evaluation, it is open to many potential causes that a wellness program will not be able to address. 6.7.6 Conclusions The newly available primary source employee data from this study has provided informa- tive descriptive statistics and statistical results. Details have been included about how pro- grams were developed, the organizing process, and the services and activities offered by each site. Where possible, the project team gathered individual-level data on workforce character- istics, participation rates, and program metrics. The metrics gathered included claims data, data on specific disorders, prescription claims, absentee hours, and workersâ compensation claims. These data have provided a big picture understanding of workforce patternsâand how variable they are. The data examined in this chapter adds to findings from the literature review on the effective- ness of health promotion programs. Although these studies may not have produced measurable Agency Operator MaintenanceBlack Male Age a Black Male Age a IndyGo 85.7% 60.9% 54.7 24.1% 93.1% 58.5 RTS 39.3% 74.9% 56.8 33.3% 98.1% 55.6 TARC 80.6% 52.3% 56.8 3.6% 98.2% 55.6 DART 31.5% 82.3% Unavailable 31.0% 97.6% Unavailable LA Metro b Unavailable Unavailable Unavailable Unavailable Unavailable Unavailable a All ages are averages. b LA Metro did not share individual-level data. Table 45. Summary of wellness program participant characteristics. Figure 22. Comparison of average annual absentee hours across sites. 0 20 40 60 80 100 120 140 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 INDY GO RTS TARC DART

90 Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line effects that translate to quantifiable cost savings for agencies, the absence of concrete statistical evidence does not mean the cases lack substantial value. The data that was collected and analyzed adds a host of new information on employee patterns of absence/sick leave and how it relates to participation in health and wellness programs among different segments of the employee population. The project team could not identify a direct relationship between the programs offered and the outcomes examined, but the process followed offers a good way to understand how agencies may undertake such evaluations regarding their own programs. Having clear data available on participants, what programs they have participated in, and for how long, could make future research easier to undertake and interpret.

Transit workers experience more health and safety problems than the general workforce, primarily as a result of a combination of physical demands, environmental factors, and stresses related to their jobs.

The TRB Transit Cooperative Research Program's TCRP Research Report 217: Improving the Health and Safety of Transit Workers with Corresponding Impacts on the Bottom Line focuses on the prevalence of these conditions, costs associated with these conditions, and statistical analysis of data on participation in and the results of health and wellness promotion programs.

Supplemental files to the report include a PowerPoint of the final briefing on the research and the Executive Summary .

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Improving students' mental health in Bangladesh

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An online career portal strengthens career guidance among secondary students in India and helps them plan for future educational and work opportunities (India)

Lessons on youth-led action towards climate advocacy and policy (India)

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The Personal Project (Morocco)

Improving adolescents’ learning in violence-affected areas through blended in-person and online learning opportunities - Communities in Harmony for Children and Adolescents (Mexico)

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Flexible pathways help build the skills and competencies of vulnerable out-of-school adolescents (United Republic of Tanzania)

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Scaling up quality early childhood education in India by investing in ongoing professional development for officials at the state, district and local levels (India)

Strengthening early childhood education in the national education plan and budget in Lesotho to help children succeed in primary and beyond (Lesotho)

Enhancing play-based learning through supportive supervision (Nigeria)

Learning social and emotional skills in pre-school creates brighter futures for children (North Macedonia)

How developing minimum standards increased access to pre-primary education (Rwanda)

Expanding access to quality early childhood education for the most excluded children (Serbia)

Advancing early learning through results-based financing (Sierra Leone)

Lessons learned from designing social impact bonds to expand preschool education (Uzbekistan)

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Strengthening policies to mainstream disability inclusion in pre-primary education (Ethiopia)

National early screening and referrals are supporting more young children with disabilities to learn (Jamaica)

Ensuring inclusive education during the pandemic and beyond (Dominican Republic)

Championing inclusive practices for children with disabilities (Ghana)

Accessible digital textbooks for children in Kenya (Kenya)

Planning for inclusion (Nepal)

Harnessing the potential of inclusive digital education to improve learning (Paraguay)

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Sparking adolescent girls' participation and interest in STEM (Ghana)

Non-formal education and the use of data and evidence help marginalized girls learn in Nepal (Nepal)

Getting girls back to the classroom after COVID-19 school closures (South Sudan)

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Creating classrooms that are responsive to the mental health needs of learners, including refugees (Poland)

Return to school (Argentina)

Learning from the education sector’s COVID-19 response to prepare for future emergencies (Bangladesh)

Prioritising learning for Rohingya children (Bangladesh)

Prioritizing children and adolescents’ mental health and protection during school reopening (Brazil)

Learning where it is difficult to learn: Radio programmes help keep children learning in Cameroon

Reaching the final mile for all migrant children to access education (Colombia)

Supporting the learning and socio-emotional development of refugee children (Colombia)

Mission Recovery (Democratic Republic of the Congo)

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Mental health and psychosocial well-being services are integrated in the education system (Ecuador)

Improving access to quality education for refugee learners (Ethiopia)

The Learning Passport and non-formal education for vulnerable children and youth (Lebanon)

Accelerated Learning Programme improves children’s learning in humanitarian settings (Mozambique)

Responding to multiple emergencies – building teachers’ capacity to provide mental health and psychosocial support before, during, and after crises (Mozambique)

Teaching at the right level to improve learning in Borno State (Nigeria)

Remedial catch-up learning programmes support children with COVID-19 learning loss and inform the national foundational learning strategy (Rwanda)

Learning solutions for pastoralist and internally displaced children (Somalia)

Recovering learning at all levels (South Africa)

How radio education helped children learn during the COVID-19 pandemic and aftermath (South Sudan)

Addressing learning loss through EiE and remedial education for children in Gaza (State of Palestine)

Providing psychosocial support and promoting learning readiness during compounding crises for adolescents in Gaza (State of Palestine)

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Adapting a remote platform in innovative ways to assess learning (Nigeria)

Assessing children's reading in indigenous languages (Peru)

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Minimising learning gaps among early-grade learners (Sri Lanka)

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Supporting Teachers to Improve Foundational Learning for Syrian Refugee Students in Jordan

Empowering teachers in Guinea: Transformative solutions for foundational learning

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A whole-school approach to improve learning, safety and wellbeing (Jamaica)

Multi-sectoral programme to improve the nutrition of school-aged adolescents (Malawi)

Parents on the frontlines of early grade reading and math (Nigeria)

Training, inspiring and motivating early grade teachers to strengthen children’s skills in literacy and numeracy (Sierra Leone) Life skills and citizenship education through Experiential Learning Objects Bank (State of Palestine)

Curriculum reform to meet the individual needs of students (Uzbekistan)

Improving early grade reading and numeracy through ‘Catch-Up,’ a remedial learning programme (Zambia)

Reimagine Education / Digital learning

Education 2.0: skills-based education and digital learning (Egypt)

Empowering adolescents through co-creation of innovative digital solutions (Indonesia)

Virtual instructional leadership course (Jamaica)

Learning Bridges accelerates learning for over 600,000 students (Jordan)

Unleashing the potential of youth through the Youth Learning Passport (Jordan)

Lessons learned from the launch of the Learning Passport Shkollat.org (Kosovo)

Opening up the frontiers of digital learning with the Learning Passport (Lao PDR)

Building teachers’ confidence and capacity to provide online learning (Maldives)

Mauritania’s first digital learning program: Akelius Digital French Course (Mauritania)

Mitigating learning loss and strengthening foundational skills through the Learning Passport (Mexico)

Expanding digital learning opportunities and connectivity for all learners (Tajikistan)

For COVID-19 education case studies, please click here and filter by area of work (Education) and type (Case Study / Field Notes).

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Case Study Research Method in Psychology

Saul Mcleod, PhD

Editor-in-Chief for Simply Psychology

BSc (Hons) Psychology, MRes, PhD, University of Manchester

Saul Mcleod, PhD., is a qualified psychology teacher with over 18 years of experience in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.

Learn about our Editorial Process

Olivia Guy-Evans, MSc

Associate Editor for Simply Psychology

BSc (Hons) Psychology, MSc Psychology of Education

Olivia Guy-Evans is a writer and associate editor for Simply Psychology. She has previously worked in healthcare and educational sectors.

On This Page:

Case studies are in-depth investigations of a person, group, event, or community. Typically, data is gathered from various sources using several methods (e.g., observations & interviews).

The case study research method originated in clinical medicine (the case history, i.e., the patient’s personal history). In psychology, case studies are often confined to the study of a particular individual.

The information is mainly biographical and relates to events in the individual’s past (i.e., retrospective), as well as to significant events that are currently occurring in his or her everyday life.

The case study is not a research method, but researchers select methods of data collection and analysis that will generate material suitable for case studies.

Freud (1909a, 1909b) conducted very detailed investigations into the private lives of his patients in an attempt to both understand and help them overcome their illnesses.

This makes it clear that the case study is a method that should only be used by a psychologist, therapist, or psychiatrist, i.e., someone with a professional qualification.

There is an ethical issue of competence. Only someone qualified to diagnose and treat a person can conduct a formal case study relating to atypical (i.e., abnormal) behavior or atypical development.

Famous Case Studies

Anna O – One of the most famous case studies, documenting psychoanalyst Josef Breuer’s treatment of “Anna O” (real name Bertha Pappenheim) for hysteria in the late 1800s using early psychoanalytic theory.
Little Hans – A child psychoanalysis case study published by Sigmund Freud in 1909 analyzing his five-year-old patient Herbert Graf’s house phobia as related to the Oedipus complex.
Bruce/Brenda – Gender identity case of the boy (Bruce) whose botched circumcision led psychologist John Money to advise gender reassignment and raise him as a girl (Brenda) in the 1960s.
Genie Wiley – Linguistics/psychological development case of the victim of extreme isolation abuse who was studied in 1970s California for effects of early language deprivation on acquiring speech later in life.
Phineas Gage – One of the most famous neuropsychology case studies analyzes personality changes in railroad worker Phineas Gage after an 1848 brain injury involving a tamping iron piercing his skull.

Clinical Case Studies

Studying the effectiveness of psychotherapy approaches with an individual patient
Assessing and treating mental illnesses like depression, anxiety disorders, PTSD
Neuropsychological cases investigating brain injuries or disorders

Child Psychology Case Studies

Studying psychological development from birth through adolescence
Cases of learning disabilities, autism spectrum disorders, ADHD
Effects of trauma, abuse, deprivation on development

Types of Case Studies

Explanatory case studies : Used to explore causation in order to find underlying principles. Helpful for doing qualitative analysis to explain presumed causal links.
Exploratory case studies : Used to explore situations where an intervention being evaluated has no clear set of outcomes. It helps define questions and hypotheses for future research.
Descriptive case studies : Describe an intervention or phenomenon and the real-life context in which it occurred. It is helpful for illustrating certain topics within an evaluation.
Multiple-case studies : Used to explore differences between cases and replicate findings across cases. Helpful for comparing and contrasting specific cases.
Intrinsic : Used to gain a better understanding of a particular case. Helpful for capturing the complexity of a single case.
Collective : Used to explore a general phenomenon using multiple case studies. Helpful for jointly studying a group of cases in order to inquire into the phenomenon.

Where Do You Find Data for a Case Study?

There are several places to find data for a case study. The key is to gather data from multiple sources to get a complete picture of the case and corroborate facts or findings through triangulation of evidence. Most of this information is likely qualitative (i.e., verbal description rather than measurement), but the psychologist might also collect numerical data.

1. Primary sources

Interviews – Interviewing key people related to the case to get their perspectives and insights. The interview is an extremely effective procedure for obtaining information about an individual, and it may be used to collect comments from the person’s friends, parents, employer, workmates, and others who have a good knowledge of the person, as well as to obtain facts from the person him or herself.
Observations – Observing behaviors, interactions, processes, etc., related to the case as they unfold in real-time.
Documents & Records – Reviewing private documents, diaries, public records, correspondence, meeting minutes, etc., relevant to the case.

2. Secondary sources

News/Media – News coverage of events related to the case study.
Academic articles – Journal articles, dissertations etc. that discuss the case.
Government reports – Official data and records related to the case context.
Books/films – Books, documentaries or films discussing the case.

3. Archival records

Searching historical archives, museum collections and databases to find relevant documents, visual/audio records related to the case history and context.

Public archives like newspapers, organizational records, photographic collections could all include potentially relevant pieces of information to shed light on attitudes, cultural perspectives, common practices and historical contexts related to psychology.

4. Organizational records

Organizational records offer the advantage of often having large datasets collected over time that can reveal or confirm psychological insights.

Of course, privacy and ethical concerns regarding confidential data must be navigated carefully.

However, with proper protocols, organizational records can provide invaluable context and empirical depth to qualitative case studies exploring the intersection of psychology and organizations.

Organizational/industrial psychology research : Organizational records like employee surveys, turnover/retention data, policies, incident reports etc. may provide insight into topics like job satisfaction, workplace culture and dynamics, leadership issues, employee behaviors etc.
Clinical psychology : Therapists/hospitals may grant access to anonymized medical records to study aspects like assessments, diagnoses, treatment plans etc. This could shed light on clinical practices.
School psychology : Studies could utilize anonymized student records like test scores, grades, disciplinary issues, and counseling referrals to study child development, learning barriers, effectiveness of support programs, and more.

How do I Write a Case Study in Psychology?

Follow specified case study guidelines provided by a journal or your psychology tutor. General components of clinical case studies include: background, symptoms, assessments, diagnosis, treatment, and outcomes. Interpreting the information means the researcher decides what to include or leave out. A good case study should always clarify which information is the factual description and which is an inference or the researcher’s opinion.

1. Introduction

Provide background on the case context and why it is of interest, presenting background information like demographics, relevant history, and presenting problem.
Compare briefly to similar published cases if applicable. Clearly state the focus/importance of the case.

2. Case Presentation

Describe the presenting problem in detail, including symptoms, duration,and impact on daily life.
Include client demographics like age and gender, information about social relationships, and mental health history.
Describe all physical, emotional, and/or sensory symptoms reported by the client.
Use patient quotes to describe the initial complaint verbatim. Follow with full-sentence summaries of relevant history details gathered, including key components that led to a working diagnosis.
Summarize clinical exam results, namely orthopedic/neurological tests, imaging, lab tests, etc. Note actual results rather than subjective conclusions. Provide images if clearly reproducible/anonymized.
Clearly state the working diagnosis or clinical impression before transitioning to management.

3. Management and Outcome

Indicate the total duration of care and number of treatments given over what timeframe. Use specific names/descriptions for any therapies/interventions applied.
Present the results of the intervention,including any quantitative or qualitative data collected.
For outcomes, utilize visual analog scales for pain, medication usage logs, etc., if possible. Include patient self-reports of improvement/worsening of symptoms. Note the reason for discharge/end of care.

4. Discussion

Analyze the case, exploring contributing factors, limitations of the study, and connections to existing research.
Analyze the effectiveness of the intervention,considering factors like participant adherence, limitations of the study, and potential alternative explanations for the results.
Identify any questions raised in the case analysis and relate insights to established theories and current research if applicable. Avoid definitive claims about physiological explanations.
Offer clinical implications, and suggest future research directions.

5. Additional Items

Thank specific assistants for writing support only. No patient acknowledgments.
References should directly support any key claims or quotes included.
Use tables/figures/images only if substantially informative. Include permissions and legends/explanatory notes.
Provides detailed (rich qualitative) information.
Provides insight for further research.
Permitting investigation of otherwise impractical (or unethical) situations.

Case studies allow a researcher to investigate a topic in far more detail than might be possible if they were trying to deal with a large number of research participants (nomothetic approach) with the aim of ‘averaging’.

Because of their in-depth, multi-sided approach, case studies often shed light on aspects of human thinking and behavior that would be unethical or impractical to study in other ways.

Research that only looks into the measurable aspects of human behavior is not likely to give us insights into the subjective dimension of experience, which is important to psychoanalytic and humanistic psychologists.

Case studies are often used in exploratory research. They can help us generate new ideas (that might be tested by other methods). They are an important way of illustrating theories and can help show how different aspects of a person’s life are related to each other.

The method is, therefore, important for psychologists who adopt a holistic point of view (i.e., humanistic psychologists ).

Limitations

Lacking scientific rigor and providing little basis for generalization of results to the wider population.
Researchers’ own subjective feelings may influence the case study (researcher bias).
Difficult to replicate.
Time-consuming and expensive.
The volume of data, together with the time restrictions in place, impacted the depth of analysis that was possible within the available resources.

Because a case study deals with only one person/event/group, we can never be sure if the case study investigated is representative of the wider body of “similar” instances. This means the conclusions drawn from a particular case may not be transferable to other settings.

Because case studies are based on the analysis of qualitative (i.e., descriptive) data , a lot depends on the psychologist’s interpretation of the information she has acquired.

This means that there is a lot of scope for Anna O , and it could be that the subjective opinions of the psychologist intrude in the assessment of what the data means.

For example, Freud has been criticized for producing case studies in which the information was sometimes distorted to fit particular behavioral theories (e.g., Little Hans ).

This is also true of Money’s interpretation of the Bruce/Brenda case study (Diamond, 1997) when he ignored evidence that went against his theory.

Breuer, J., & Freud, S. (1895). Studies on hysteria . Standard Edition 2: London.

Curtiss, S. (1981). Genie: The case of a modern wild child .

Diamond, M., & Sigmundson, K. (1997). Sex Reassignment at Birth: Long-term Review and Clinical Implications. Archives of Pediatrics & Adolescent Medicine , 151(3), 298-304

Freud, S. (1909a). Analysis of a phobia of a five year old boy. In The Pelican Freud Library (1977), Vol 8, Case Histories 1, pages 169-306

Freud, S. (1909b). Bemerkungen über einen Fall von Zwangsneurose (Der “Rattenmann”). Jb. psychoanal. psychopathol. Forsch ., I, p. 357-421; GW, VII, p. 379-463; Notes upon a case of obsessional neurosis, SE , 10: 151-318.

Harlow J. M. (1848). Passage of an iron rod through the head. Boston Medical and Surgical Journal, 39 , 389–393.

Harlow, J. M. (1868). Recovery from the Passage of an Iron Bar through the Head . Publications of the Massachusetts Medical Society. 2 (3), 327-347.

Money, J., & Ehrhardt, A. A. (1972). Man & Woman, Boy & Girl : The Differentiation and Dimorphism of Gender Identity from Conception to Maturity. Baltimore, Maryland: Johns Hopkins University Press.

Money, J., & Tucker, P. (1975). Sexual signatures: On being a man or a woman.

Further Information

Case Study Approach
Case Study Method
Enhancing the Quality of Case Studies in Health Services Research
“We do things together” A case study of “couplehood” in dementia
Using mixed methods for evaluating an integrative approach to cancer care: a case study

Research Methodology

Qualitative Data Coding

What Is a Focus Group?

Cross-Cultural Research Methodology In Psychology

What Is Internal Validity In Research?

Research Methodology , Statistics

What Is Face Validity In Research? Importance & How To Measure

Criterion Validity: Definition & Examples

The importance of patient case studies in delivery of evidence-based care

Posted On 3 Jun, 2024 Read Time 3 min Tags case study , clinical education , collaboration , evidence-based care , NALHN , ophthalmology , podcast , rare conditions

Ongoing education is a core aspect of healthcare delivery at Central Adelaide Local Health Network (CALHN).

But with busy schedules and only so many hours in the day, it can be challenging for clinicians to keep up-to-date with all the specialist areas of health. That’s why published patient case studies are so valuable.

“Doctors share case studies to spread knowledge about unique or rare clinical scenarios they encounter,” said CALHN Basic Physician Trainee Dr Brandon Stretton. “By publishing these cases, they help other healthcare professionals learn from their experiences, which can be incredibly useful in diagnosing and treating future patients.” “Case studies are a way to contribute to the collective knowledge and improve patient care across the board.”

A case study is a write-up of the presentation and clinical management of a specific patient, with all personal details removed and consent provided.

Sudden vision loss – but what’s causing it?

Dr Stretton and CALHN opthalmologist Dr Sumu Simon recently published a case study about a man who presented to the emergency department reporting sudden onset vision loss in his right eye lasting several hours. The case is also presented in a recent episode of the Royal Australasian College of Physicians podcast, Pomegranate Health, which was prepared in collaboration with clinicians from Northern Adelaide Local Health Network (NALHN).

“This case is particularly significant because it highlights a sight-threatening manifestation of a systemic disease, which is crucial for clinicians to recognise and engage the appropriate multi-disciplinary teams,” Dr Stretton said. “Awareness of such cases can lead to prompt diagnosis and treatment, potentially preventing serious complications.” “Publishing and discussing this case helps to inform and educate a wide range of healthcare providers about the condition, its diagnosis, and the latest treatment approaches.”

In this case, the patient was effectively managed through accurate identification and timely management of the cause of his vision loss.

Keeping up-to-date

Dr Stretton said case studies play an important role in medical education.

“Many doctors, including myself, do regularly read case studies,” he says. “Case studies are particularly engaging and educational, offering practical insights that can be directly applied to patient care.” “Case studies are often used in training and ongoing professional development because they provide real-life contexts that enhance understanding and retention of medical knowledge.”

When included in reputable medical journals, case studies undergo a rigorous peer-review process – that is, they are scrutinised by experts in the field before publication.

Read the research

With co-authors Dr Yiran Tan and Dr Mark Hassall, Dr Stretton and Dr Simon published the paper The Role of Tocilizumab in Glucocorticoid Resistant Giant Cell Arteritis: A Case Series and Literature Review in the Journal of Neuro-Ophthalmology.

The podcast episode is hosted by Neurology Registrar Dr Stephen Bacchi from NALHN.

If you have published a case report that may benefit others through discussion in a podcast format, please reach out to Dr Stretton ([email protected]) and Dr Bacchi ([email protected]).

Rural and regional patients are satisfied with telehealth research shows

Local disparities may prevent national vaccination efforts for rubella

When public health officials make policies about when and how vaccination programs are implemented, they must weigh the benefits and risks of how infectious diseases spread throughout the country. However, these analyses are often based on national-level data and, in some countries, may overlook nuances at the local level.

A new analysis by an international team, including Penn State researchers, revealed that the resulting recommendations may keep some countries from realizing the benefits of vaccination and globally eradicating diseases, such as rubella -- a contagious viral infection that causes mild symptoms in children. The team examined data from Nigeria, one of 19 countries that hasn't yet introduced rubella vaccination, as a case study. Their findings were published in the journal Vaccine.

"It's this interesting challenge where rubella is a mild disease if you get it as a kid, but it's high risk if you get it as an adult," said senior author Matthew Ferrari, professor of biology and director of the Center for Infectious Disease Dynamics at the Huck Institutes of Life Sciences at Penn State. "All of the policy surrounding rubella vaccination has been guided by that risk in adults, which has been holding back the benefit of rubella vaccination in some countries."

The primary concern among adults is the potential risk for congenital rubella syndrome (CRS), a serious health condition that can occur if a pregnant person contracts the virus. When an infectious disease like rubella is common, people are more likely to contract it earlier in life. And because the rubella virus is immunizing, those who are infected as children won't have pregnancies at risk of CRS when they are older.

Vaccination, on the other hand, reduces the amount of circulating virus, meaning individuals who were not vaccinated as children are less likely to be infected with rubella by adolescence or adulthood, Ferrari explained. As a result, even as the total number of rubella cases goes down with vaccination, the number of rubella infections in people of reproductive age -- who were neither infected nor vaccinated as children -- increases, putting those pregnancies at risk of CRS. Because of this complex dynamic, the World Health Organization (WHO) recommends that countries demonstrate that they can achieve a coverage level of 80% or greater, through either routine immunization or supplemental campaigns, before introducing rubella vaccination. The conventional wisdom has been that when vaccination coverage is above this threshold, the reduced risk of CRS due to less rubella virus offsets the paradoxical increase in CRS risk because infections tend to happen later in life, Ferrari explained.

The research team, working in partnership with the U.S. Centers of Disease Control and Prevention and the Nigeria Centre for Disease Control and Prevention, studied the epidemiology of rubella in Nigeria. Rubella is a comparatively rare disease, so it's difficult to quantify the potential harm and risk of CRS. These assessments are further complicated by the fact that Nigeria, Ferrari said, is a country with disparate ranges of wealth, vaccination coverage, health care access and birth rates, all of which play a role in infection and CRS risk.

To gain a better understanding of the factors at play, the team analyzed data from a nationally representative serosurvey, which detects the presence of antibodies in blood. The data allowed the researchers to see how many people, particularly women of reproductive age, had rubella antibodies, how many were potentially at risk of rubella infection and where the infection risk was greatest geographically. They identified regional differences in transmission between the northern versus southern part of the country, finding that transmission in the north was two-times higher compared to the south. They were also able to estimate the number of pregnancies affected by rubella infection today.

"We grounded the current infection risk and potential pregnancies at risk in strong empirical data and real-world phenomena," Ferrari said. "Parts of the country can already vaccinate more than 80% of kids, based on their current rate of measles vaccination, but low vaccination coverage in the north is a barrier to introduction across the whole country under the current recommendation."

What's more, the concern about increased CRS cases may not be as bad as conventionally believed, Ferrari noted. The team's new estimates of transmission rates show that the 80% threshold is conservative and that introducing a rubella vaccination program in Nigeria today could reduce the number of CRS cases by thousands in the first five years. "Some states could see CRS risk increase by hundreds of cases," he said, "but that increased risk would not come to fruition until 10 years down the road" -- providing a decade for public health officials to implement policies and programs to prevent this possibility.

"Strengthening and improving routine immunization programs and advancing them everywhere in the world is a benefit to everyone in the world. The more we do this, the elimination of rubella as a virus on this planet is entirely feasible," Ferrari said.

Mumps, Measles, Rubella
Infectious Diseases
Diseases and Conditions
Public Health
Disaster Plan
Travel and Recreation
STEM Education
Public health
MMR vaccine
Epidemiology
Vaccination

Story Source:

Materials provided by Penn State . Original written by Christine Yu. Note: Content may be edited for style and length.

Journal Reference :

Taishi Nakase, Tenley Brownwright, Oyeladun Okunromade, Abiodun Egwuenu, Oladipo Ogunbode, Bola Lawal, Kayode Akanbi, Gavin Grant, Orji O. Bassey, Melissa M. Coughlin, Bettina Bankamp, Ifedayo Adetifa, C. Jessica E. Metcalf, Matthew Ferrari. The impact of sub-national heterogeneities in demography and epidemiology on the introduction of rubella vaccination programs in Nigeria . Vaccine , 2024; DOI: 10.1016/j.vaccine.2024.05.030

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40 Facts About Elektrostal

Written by Lanette Mayes

Modified & Updated: 01 Jun 2024

Reviewed by Jessica Corbett

Elektrostal is a vibrant city located in the Moscow Oblast region of Russia. With a rich history, stunning architecture, and a thriving community, Elektrostal is a city that has much to offer. Whether you are a history buff, nature enthusiast, or simply curious about different cultures, Elektrostal is sure to captivate you.

This article will provide you with 40 fascinating facts about Elektrostal, giving you a better understanding of why this city is worth exploring. From its origins as an industrial hub to its modern-day charm, we will delve into the various aspects that make Elektrostal a unique and must-visit destination.

So, join us as we uncover the hidden treasures of Elektrostal and discover what makes this city a true gem in the heart of Russia.

Key Takeaways:

Elektrostal, known as the “Motor City of Russia,” is a vibrant and growing city with a rich industrial history, offering diverse cultural experiences and a strong commitment to environmental sustainability.
With its convenient location near Moscow, Elektrostal provides a picturesque landscape, vibrant nightlife, and a range of recreational activities, making it an ideal destination for residents and visitors alike.

Known as the “Motor City of Russia.”

Elektrostal, a city located in the Moscow Oblast region of Russia, earned the nickname “Motor City” due to its significant involvement in the automotive industry.

Home to the Elektrostal Metallurgical Plant.

Elektrostal is renowned for its metallurgical plant, which has been producing high-quality steel and alloys since its establishment in 1916.

Boasts a rich industrial heritage.

Elektrostal has a long history of industrial development, contributing to the growth and progress of the region.

Founded in 1916.

The city of Elektrostal was founded in 1916 as a result of the construction of the Elektrostal Metallurgical Plant.

Located approximately 50 kilometers east of Moscow.

Elektrostal is situated in close proximity to the Russian capital, making it easily accessible for both residents and visitors.

Known for its vibrant cultural scene.

Elektrostal is home to several cultural institutions, including museums, theaters, and art galleries that showcase the city’s rich artistic heritage.

A popular destination for nature lovers.

Surrounded by picturesque landscapes and forests, Elektrostal offers ample opportunities for outdoor activities such as hiking, camping, and birdwatching.

Hosts the annual Elektrostal City Day celebrations.

Every year, Elektrostal organizes festive events and activities to celebrate its founding, bringing together residents and visitors in a spirit of unity and joy.

Has a population of approximately 160,000 people.

Elektrostal is home to a diverse and vibrant community of around 160,000 residents, contributing to its dynamic atmosphere.

Boasts excellent education facilities.

The city is known for its well-established educational institutions, providing quality education to students of all ages.

A center for scientific research and innovation.

Elektrostal serves as an important hub for scientific research, particularly in the fields of metallurgy , materials science, and engineering.

Surrounded by picturesque lakes.

The city is blessed with numerous beautiful lakes , offering scenic views and recreational opportunities for locals and visitors alike.

Well-connected transportation system.

Elektrostal benefits from an efficient transportation network, including highways, railways, and public transportation options, ensuring convenient travel within and beyond the city.

Famous for its traditional Russian cuisine.

Food enthusiasts can indulge in authentic Russian dishes at numerous restaurants and cafes scattered throughout Elektrostal.

Home to notable architectural landmarks.

Elektrostal boasts impressive architecture, including the Church of the Transfiguration of the Lord and the Elektrostal Palace of Culture.

Offers a wide range of recreational facilities.

Residents and visitors can enjoy various recreational activities, such as sports complexes, swimming pools, and fitness centers, enhancing the overall quality of life.

Provides a high standard of healthcare.

Elektrostal is equipped with modern medical facilities, ensuring residents have access to quality healthcare services.

Home to the Elektrostal History Museum.

The Elektrostal History Museum showcases the city’s fascinating past through exhibitions and displays.

A hub for sports enthusiasts.

Elektrostal is passionate about sports, with numerous stadiums, arenas, and sports clubs offering opportunities for athletes and spectators.

Celebrates diverse cultural festivals.

Throughout the year, Elektrostal hosts a variety of cultural festivals, celebrating different ethnicities, traditions, and art forms.

Electric power played a significant role in its early development.

Elektrostal owes its name and initial growth to the establishment of electric power stations and the utilization of electricity in the industrial sector.

Boasts a thriving economy.

The city’s strong industrial base, coupled with its strategic location near Moscow, has contributed to Elektrostal’s prosperous economic status.

Houses the Elektrostal Drama Theater.

The Elektrostal Drama Theater is a cultural centerpiece, attracting theater enthusiasts from far and wide.

Popular destination for winter sports.

Elektrostal’s proximity to ski resorts and winter sport facilities makes it a favorite destination for skiing, snowboarding, and other winter activities.

Promotes environmental sustainability.

Elektrostal prioritizes environmental protection and sustainability, implementing initiatives to reduce pollution and preserve natural resources.

Home to renowned educational institutions.

Elektrostal is known for its prestigious schools and universities, offering a wide range of academic programs to students.

Committed to cultural preservation.

The city values its cultural heritage and takes active steps to preserve and promote traditional customs, crafts, and arts.

Hosts an annual International Film Festival.

The Elektrostal International Film Festival attracts filmmakers and cinema enthusiasts from around the world, showcasing a diverse range of films.

Encourages entrepreneurship and innovation.

Elektrostal supports aspiring entrepreneurs and fosters a culture of innovation, providing opportunities for startups and business development .

Offers a range of housing options.

Elektrostal provides diverse housing options, including apartments, houses, and residential complexes, catering to different lifestyles and budgets.

Home to notable sports teams.

Elektrostal is proud of its sports legacy , with several successful sports teams competing at regional and national levels.

Boasts a vibrant nightlife scene.

Residents and visitors can enjoy a lively nightlife in Elektrostal, with numerous bars, clubs, and entertainment venues.

Promotes cultural exchange and international relations.

Elektrostal actively engages in international partnerships, cultural exchanges, and diplomatic collaborations to foster global connections.

Surrounded by beautiful nature reserves.

Nearby nature reserves, such as the Barybino Forest and Luchinskoye Lake, offer opportunities for nature enthusiasts to explore and appreciate the region’s biodiversity.

Commemorates historical events.

The city pays tribute to significant historical events through memorials, monuments, and exhibitions, ensuring the preservation of collective memory.

Promotes sports and youth development.

Elektrostal invests in sports infrastructure and programs to encourage youth participation, health, and physical fitness.

Hosts annual cultural and artistic festivals.

Throughout the year, Elektrostal celebrates its cultural diversity through festivals dedicated to music, dance, art, and theater.

Provides a picturesque landscape for photography enthusiasts.

The city’s scenic beauty, architectural landmarks, and natural surroundings make it a paradise for photographers.

Connects to Moscow via a direct train line.

The convenient train connection between Elektrostal and Moscow makes commuting between the two cities effortless.

A city with a bright future.

Elektrostal continues to grow and develop, aiming to become a model city in terms of infrastructure, sustainability, and quality of life for its residents.

In conclusion, Elektrostal is a fascinating city with a rich history and a vibrant present. From its origins as a center of steel production to its modern-day status as a hub for education and industry, Elektrostal has plenty to offer both residents and visitors. With its beautiful parks, cultural attractions, and proximity to Moscow, there is no shortage of things to see and do in this dynamic city. Whether you’re interested in exploring its historical landmarks, enjoying outdoor activities, or immersing yourself in the local culture, Elektrostal has something for everyone. So, next time you find yourself in the Moscow region, don’t miss the opportunity to discover the hidden gems of Elektrostal.

Q: What is the population of Elektrostal?

A: As of the latest data, the population of Elektrostal is approximately XXXX.

Q: How far is Elektrostal from Moscow?

A: Elektrostal is located approximately XX kilometers away from Moscow.

Q: Are there any famous landmarks in Elektrostal?

A: Yes, Elektrostal is home to several notable landmarks, including XXXX and XXXX.

Q: What industries are prominent in Elektrostal?

A: Elektrostal is known for its steel production industry and is also a center for engineering and manufacturing.

Q: Are there any universities or educational institutions in Elektrostal?

A: Yes, Elektrostal is home to XXXX University and several other educational institutions.

Q: What are some popular outdoor activities in Elektrostal?

A: Elektrostal offers several outdoor activities, such as hiking, cycling, and picnicking in its beautiful parks.

Q: Is Elektrostal well-connected in terms of transportation?

A: Yes, Elektrostal has good transportation links, including trains and buses, making it easily accessible from nearby cities.

Q: Are there any annual events or festivals in Elektrostal?

A: Yes, Elektrostal hosts various events and festivals throughout the year, including XXXX and XXXX.

Elektrostal's fascinating history, vibrant culture, and promising future make it a city worth exploring. For more captivating facts about cities around the world, discover the unique characteristics that define each city . Uncover the hidden gems of Moscow Oblast through our in-depth look at Kolomna. Lastly, dive into the rich industrial heritage of Teesside, a thriving industrial center with its own story to tell.

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v.2023; 2023
PMC11114595

Systems Thinking for Public Health: A Case Study Using U.S. Public Education

Elizabeth ashby.

National Academies of Sciences, Engineering, and Medicine

Charlie Minicucci

Danilo buonsenso.

Fondazione Policlinico Universitario Agostino Gemelli IRCCS

Sebastián González-Dambrauskas

LARed: Red Colaborativa Pediátrica de Latinoamérica

Rafael Obregón

Children’s Hospital of Orange County

William Hallman

Rutgers University

Chandy John

Indiana University School of Medicine

November 7, 2023

ABSTRACT | The initial response to the COVID-19 pandemic in the United States largely focused on addressing the immediate health consequences from the emergent pathogen. This initial focus often ignored the related impacts from the pandemic and from mitigation measures, including how existing social determinants of health compounded physical, social, and economic impacts on individuals who have historically been marginalized. The consequences of decisions around closing and reopening primary and secondary (K—12 in the United States) public schools exemplify the complex impacts of pandemic mitigation measures. Ongoing COVID-19 mitigation and recovery efforts have gradually begun addressing indirect consequences, but these efforts were slow to be identified and adopted through much of the acute phase of the pandemic, mirroring the decades-long neglect of contributors to the overall health and well-being of populations that have been made to be vulnerable.

A systems approach for decision making and problem solving holistically considers the effects of complex interacting factors. Taking a systems approach at the start of the next health emergency could encourage response strategies that consider various competing public health needs throughout different sectors of society, account for existing disparities, and preempt undesirable consequences before and during response implementation. There is a need to understand how a systems approach can be better integrated into decision making to improve future responses to public health emergencies. A wide range of stakeholders should contribute expertise to these models, and these partnerships should be formed in advance of a public health emergency.

Introduction

In September 2021 the National Academies of Sciences, Engineering, and Medicine hosted a workshop titled “Towards a Post-Pandemic World: Lessons from COVID-19 for Now and the Future.” ( NASEM, 2022 ) In this article, select workshop participants further explore the application of systems thinking in evaluating COVID-19 mitigation measures.

Systems Thinking in Public Health

A systems science approach to outbreak response planning is a useful tool for broadening strategic thinking to consider critical factors driving the short- and long-term consequences of crisis response measures, including how such decisions will impact health disparities ( Bradley et al., 2020 ). A conceptual framework, systems thinking accounts for the relationship between individual factors within a scenario as well as their contributions to the whole, and can facilitate the synthesis of response plans that match the scale and complexity of the problem at hand ( Trochim et al., 2006 ).

Specifically for public health, a systems approach “applies scientific insights to understand the elements that influence health outcomes; models the relationships between those elements; and alters design, processes or policies based on the resultant knowledge” ( Kaplan et al., 2013 ). Complex and interconnected risk factors collectively influenced health outcomes in the COVID-19 pandemic. Response to an evolving public health emergency requires a systems approach that can weigh disparate needs and account for systemic inequities to quickly generate solutions while remaining adaptable as new data emerges.

addresses the inherent complexity of societal impacts during public health emergencies,
accounts for social determinants of health, and
includes perspectives from a wide range of stakeholders.

COVID-19 Decision Making and Unintended Consequences

At the start of the COVID-19 pandemic, policy decisions and responses were enacted quickly to contain the spread of disease. However, the public health implications of COVID-19 extend beyond the disease itself, as the pandemic exacerbated disparities in health outcomes closely correlated with social determinants of health and structural inequalities ( Karmakar et al., 2021 ; Liao and De Maio 2021 ; Webb Hooper et al., 2020 ). While strong infection control measures, such as lockdowns and school closures, were considered essential when COVID-19 was an emergent disease, these responses resulted in unintended consequences that were not prioritized in the early decision-making process ( Turcotte-Tremblay et al., 2021 ).

This trade-off may have been necessary at the time, given the rapid disease spread and lack of data about the disease to guide initial decisions. However, as the potential for containment or eradication of COVID-19 dimmed, decision makers were slow to update mitigation measures based on evolving knowledge and accounting for the broader population health needs. The COVID-19 response stemmed largely from concern about acute infections, reflecting a mindset that was more focused on medical response than broader public health impacts.

Biological factors (e.g., age or comorbidities such as hypertension, diabetes, lung disease, or immunodeficiencies) and social determinants of health (e.g., disparities stemming from marginalized socioeconomic status, lack of access to housing and transportation, race and ethnicity, and language and literacy barriers) interact to affect health and well-being ( WHO, 2023 ; Gao et al., 2021 ). While awareness of biological risk factors for severe illness grew rapidly and mitigation measures were enacted to protect individuals at risk, consideration for social risk factors in COVID response plans were not equally prioritized ( Laylavi, 2021 ).

For example, while the federal government heavily invested in the development of vaccines and anti-viral treatments early in the pandemic ( Lalani et al., 2023 ), expanded unemployment support to address pandemic-related job losses and educational support for students during school closures were deprioritized and debated at length in government. This inaction slowed critical support for populations disproportionately impacted by pandemic spread-related closures.

The neglect of programs that would create a social safety net for the populations most marginalized is not specific to the pandemic, but is an exacerbation of systematic neglect over decades ( Mody et al., 2022 ; Dorn et al., 2020 ; Saenz and Sparks, 2020 ). Even when educational support programs were rolled out, they were implemented inconsistently and did not specifically consider the additional needs of populations that have been made to be vulnerable and that were more likely to be disproportionately impacted by school closures and loss of income due to pandemic restrictions ( Wright, 2021 ).

There have been earlier calls to apply a systems approach to improve public health outcomes, and many examples exist to illustrate the strength of a systems approach in successfully addressing complex public health challenges ( Kaplan et al., 2013 ; Honoré et al., 2011 ). The example of public school closures demonstrates how the social impacts of mitigation measures widened existing disparities. The example also highlights the need for holistic, systems-based approaches in addressing future public health crises.

Public School Closures and Remote Learning: A Case for Applying Systems Thinking to Improve Health Outcomes during Future Disease Outbreaks

The issue of school closures during the pandemic serves as a case study for how factors affecting health were not holistically considered during decision making. School closures can exacerbate social and health disparities, with long-lasting consequences ( NASEM, 2020 ). Many students rely on school systems for adequate nutrition, safety, supervision, and socioemotional and cognitive development ( Van Lancker and Parolin, 2020 ).

In addition, substantial evidence shows that remote learning is an inadequate and unequitable substitute for in-person learning and does not completely mitigate learning losses during school closures ( Agostinelli et al., 2022 ; Engzell et al., 2021 ; Bettinger and Loeb, 2017 ).

Furthermore, school closures may have a greater impact on students in underserved communities. Systemically disadvantaged students (e.g., those who are experiencing poverty or are from racial or ethnic minority communities) are less likely to have access to the technology or broadband internet that is necessary for remote learning. They are less likely to have parents who are able to work from home and supervise them and often encounter other barriers to achieving learning goals ( Smith and Reeves, 2020 ). Students with special educational needs have had disproportionate learning losses and have limited access to other supportive resources otherwise provided through schools while schools are closed ( Hurwitz et al., 2021 ; Nelson and Murakami, 2020 ).

The decision making surrounding school closures is complex ( Allen, 2021 ; World Bank Group Education, 2020 ). While decision makers now know that K–12 public school children have reduced physical risk to severe disease outcomes from COVID-19 compared to adults, school closures were implemented early in the pandemic, when this risk was unknown and there was limited time for decision making. Students experienced related impacts from pandemic mitigation measures, and some have suffered mentally, emotionally, and developmentally as a direct result of school closures specifically ( Viner et al., 2022 ; Engzell et al., 2021 ).

However, decisions about school closures and transitions to remote learning at the start of the COVID-19 pandemic generally focused on physical health risk factors (e.g., preventing transmission and mortality) rather than holistic evaluations of children’s multifaceted developmental needs (e.g., socialization in cognitive and emotional development; Viner et al., 2022 ). Factors such as public fear and parental pressure may have also affected decisions both to close and reopen schools. Many under-resourced schools may have also had limited ability to facilitate a safe return to in-person learning. The many factors affecting school closure decisions further demonstrates the overall need for a systematic, context-specific model for decision making in future emergencies.

Widespread school closures lasted well into 2021, despite early and repeated warnings about the potential costs to student well-being ( Allen, 2021 ; Kaffenberger, 2021 ; Balingit and Meckler, 2020 ) and evidence that with adequate interventions, in-person schooling could be made safe ( Alonso et al., 2022 ; Rotevatn et al., 2022 ; Head et al., 2021 ).

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Object name is nampsp-2023-202311a-gfigure_1.jpg

SOURCE: Los Angeles Almanac. 2020. Ethnic distribution of pupils by school districts: Los Angeles County: School year 2019–2020. Available at: http://www.laalmanac.com/education/ed05.php (accessed January 13, 2023).

NOTE: Each series comprises the 10 percent of school districts with the highest and lowest proportions of minority students. The red box highlights a stark difference in school closures between the two groups during the 2020–2021 academic year.

Figure 1 was developed with data from the California Department of Education via the Los Angeles Almanac (2020) and depicts the disparity between closure rates for schools in Los Angeles County, represented by the proportion of a district’s ethnic minority students. Schools were considered closed if the district saw a greater than 50 percent decline in foot traffic in 2020 over the same month in 2019, when schools were still open, according to the US School Closure and Distance Learning Database’s use of anonymized mobile phone location data ( Parolin and Lee, 2021 ).

School student counts and ethnic compositions are as reported for the 2019–2020 school year by the California Department of Education via the Los Angeles Almanac (2020) . Proportions are averaged across all the districts selected. The lowest percent minority district set includes the 10 percent of Los Angeles County districts with the highest proportion of non-minority students (n = 8; all more than 45 percent White). This set covers about 115 schools educating over 87,000 students (about 5.9 percent of the Los Angeles County total). No closure data were available for one small district (Hermosa Beach City; 1,378 students; 67.5 percent White) and one independent school (Hughes-Elizabeth Lakes Union Elementary; 196 students; 64.8 percent White). They were excluded and replaced by two districts further down the scale.

The highest percent minority district set includes the 10 percent of Los Angeles County districts with the largest proportion of minority students (n = 9; though two separate parts of one district were tracked separately: all more than 98 percent minority). This set covers about 125 schools educating over 93,000 students (about 6.3 percent of the Los Angeles County total). Of note, closure data for Lennox School District (13,818 students; 0.7 percent White) were unavailable for the first half of 2021. It is not included in the averaged value on the graph for those months.

A similar analysis (data not shown) was conducted for the top and bottom quartiles (instead of decile) and showed a similar, though less pronounced, difference between the two series. Chartered public schools were excluded from this analysis.

Multiple factors must also be accounted for in remediation plans, not just initial decision making, in response to a public health crisis. In July 2021, the Center on Reinventing Public Education ( CRPE, 2022 ) evaluated published plans from 100 major US school districts on spending the more than $43 billion allocated from the Elementary and Secondary School Emergency Relief Fund. While most districts included learning loss and social, emotional, and mental health as key target areas for remediation, only about 30 percent of schools accounted for special needs, equity, and community engagement in their remediation plans (see Figure 2 ). This data revealed that many school districts have attempted to address pandemic-related health outcomes, but these efforts can be further improved with a more holistic approach to decision making regarding public education and student health.

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Object name is nampsp-2023-202311a-gfigure_2.jpg

SOURCE: Data accessed from: Center on Reinventing Public Education. 2022. 2021–2022 School District Plans Database. Available at: https://crpe.org/pandemic-learning/tracking-district-actions/ (accessed October 17, 2023).

Students’ well-being and long-term health outcomes are not the only considerations in deciding when best to resume in-person learning. Plans for safe and sustainable resumption of in-person learning also need to consider the needs and concerns of other stakeholders, such as parents, school staff (including nurses and health human resources), and public officials. For example, federal school reopening strategies included practices to safeguard the well-being of educators and other school staff ( Department of Education, 2021 ). Other concerns include the need for data to understand and mitigate transmission dynamics within classrooms and in the local community, especially with the emergence of new viral variants ( Honein et al., 2021 ). These complexities further underline the need for a holistic decision-making strategy that accounts for different needs and dynamics as information unfolds during a public health emergency such as the COVID-19 pandemic.

Using Systems Thinking to Redefine Strategies for Public Health Preparedness

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Object name is nampsp-2023-202311a-gfigure_3.jpg

SOURCE: Sahin, O., H. Salim, E. Suprun, R. Richards, S. MacAskill, S. Heilgeist, S. Rutherford, R. A. Stewart, and C. D. Beal. 2020. Developing a preliminary causal loop diagram for understanding the wicked complexity of the COVID-19 pandemic. Systems 8(2):20. https://doi.org/10.3390/systems8020020 .

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Object name is nampsp-2023-202311a-gfigure_4.jpg

SOURCE: Bradley, D. T., M. A. Mansouri, F. Kee, and L. M. T. Garcia. 2020. A systems approach to preventing and responding to COVID-19. eClinicalMedicine 21:100325. https://doi.org/10.1016/j.eclinm.2020.100325 ; Walsh, S., A. Chowdhury, V. Braithwaite, S. Russell, J. M. Birch, J. L. Ward, C. Waddington, C. Brayne, C. Bonell, R. M. Viner, and O. T. Mytton. 2021. Do school closures and school reopenings affect community transmission of COVID-19? A systematic review of observational studies. BMJ Open 11(8):e053371. https://doi.org/10.1136/bmjopen-2021-053371 ; Centers for Disease Control and Prevention (CDC). 2022. Operational Guidance for K-12 Schools and Early Care and Education Programs to Support Safe In-Person Learning. Available at: https://www.cdc.gov/coronavirus/2019-ncov/community/schools-childcare/k-12-childcare-guidance.html (accessed October 17, 2023); Alonso, S., M. Català, D. López, E. Álvarez-Lacalle, I. Jordan, J. J. García-García, V. Fumadó, C. Muñoz-Almagro, E. Gratacós, N. Balanza, R. Varo, P. Millat, B. Baro, S. Ajanovic, S. Arias, J. Claverol, M. F. de Sevilla, E. Bonet-Carne, A. Garcia-Miquel, E. Coma, M. Medina-Peralta, F. Fina, C. Prats, and Q. Bassat. 2022. Individual prevention and containment measures in schools in Catalonia, Spain, and community transmission of SARS-CoV-2 after school re-opening. PLOS ONE 17(2):e0263741. https://doi.org/10.1371/journal.pone.0263741 ; and Head, J. R., K. L. Andrejko, Q. Cheng, P. A. Collender, S. Phillips, A. Boser, A. K. Heaney, C. M. Hoover, S. L. Wu, G. R. Northrup, K. Click, N. S. Bardach, J. A. Lewnard, and J. V. Remais. 2021. School closures reduced social mixing of children during COVID-19 with implications for transmission risk and school reopening policies. Journal of the Royal Society Interface 18(177):20200970. https://doi.org/10.1098/rsif.2020.0970 .

NOTE: Generated by authors using Miro online whiteboard. The green box indicates a hypothetical decision maker’s position in the system. Yellow boxes highlight central aspects of the system that a decision maker might attempt to affect directly. Plus and minus signs indicate positive or negative causal relationships. Green symbols indicate a desirable causal relationship, red symbols indicate an undesirable causal relationship, and question marks indicate relationships of unknown nature as a result of knowledge gaps (in the case of school closures impacting transmission) or key decisions that have yet to be made (e.g., whether learning continuity plans choose to encourage or discourage school closures). Colored arrows highlight examples of positive feedback loops in the system: green arrows denote a loop of desirable causal relationships that decision makers may want to reinforce, and red arrows denote one that may be targeted for disruption.

While providing substantial benefits, developing CLDs also presents challenges. Because systems are inherently complex, it is difficult to capture all relevant factors in a diagram while maintaining the detail that is needed to be useful. Also, translating a CLD into action can be challenging, as evidenced by the lack of actionable CLDs that address the impacts of the COVID-19 pandemic. Despite these challenges, CLDs remain a useful tool for providing a decision-making framework in complex situations with interconnected factors.

The U.S. response strategy to the COVID-19 pandemic suffered from a lack of a holistic and systems-oriented approach to decision making. This paper outlines the complexities that should have been considered in making the shift to fully remote learning in K–12 schools during COVID-19. There is a need to integrate diverse perspectives from interdisciplinary experts, stakeholders, and community members in developing models that influence decision making. In the example of school closures, educators, parents, school health leaders, and community leaders are relevant stakeholders for public health decisions that affect health outcomes in schools.

Systems approaches facilitate more comprehensive assessments to inform decision making, and CLDs are a valuable tool that can be used for response planning. Time is of the essence in a public health emergency, especially when there is minimal information about an emerging threat. Systems models can be built to respond to an emerging threat and developed as information is gained.

Despite the widely acknowledged usefulness of CLDs, there are few examples of CLDs that were applied during the COVID-19 pandemic to influence decision making. Partnerships between public health experts and decision makers should be developed in advance of public health emergencies, so they will be poised to respond immediately. Further, perspectives from the economic and social sectors should also be sought, to understand the complex impact of emergencies, including the impacts of mitigation measures. Increased stakeholder engagement can result in tools that are more actionable and effective.

A commitment to incorporate systems thinking will require broadening the preparedness planning approach for public health decision making, emphasizing the inclusion of physical and related impacts, and securing buy-in from decision makers ( Zięba, 2021 ; Klement, 2020 ). This type of thinking would also require training, so the public health workforce can learn to design and implement these methods.

Acknowledgments

Charlie Minicucci and Elizabeth Ashby contributed equally to this work.

This manuscript benefited from the thoughtful input of Jessica G Burke, University of Pittsburgh; Erin D. Maughan, George Mason University; and Carol Walsh, National Association of School Nurses.

Funding Statement

Conflict-of-Interest Disclosures: Danilo. Buonsenso discloses funding from Pfizer outside the submitted work.

Contributor Information

Elizabeth Ashby, National Academies of Sciences, Engineering, and Medicine.

Charlie Minicucci, National Academies of Sciences, Engineering, and Medicine.

Julie Liao, National Academies of Sciences, Engineering, and Medicine.

Danilo Buonsenso, Fondazione Policlinico Universitario Agostino Gemelli IRCCS.

Sebastián González-Dambrauskas, LARed: Red Colaborativa Pediátrica de Latinoamérica.

Rafael Obregón, UNICEF.

Matt Zahn, Children’s Hospital of Orange County.

William Hallman, Rutgers University.

Chandy John, Indiana University School of Medicine.

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Moscow, city, capital of Russia, located in the far western part of the country.Since it was first mentioned in the chronicles of 1147, Moscow has played a vital role in Russian history. It became the capital of Muscovy (the Grand Principality of Moscow) in the late 13th century; hence, the people of Moscow are known as Muscovites.Today Moscow is not only the political centre of Russia but ...
Systems Thinking for Public Health: A Case Study Using U.S. Public
Systems Thinking in Public Health. A systems science approach to outbreak response planning is a useful tool for broadening strategic thinking to consider critical factors driving the short- and long-term consequences of crisis response measures, including how such decisions will impact health disparities (Bradley et al., 2020).A conceptual framework, systems thinking accounts for the ...