Understanding the Modifiable Determinants of Health

for those Working in the Film and TV Industries.

(draft 1.f)

Paul Heinzelmann, MD, MPH

Founder, SetMD (www.setmd.care); Director, Safe Sets - Dying to Work in the Film Industry

• This paper is considered a starting point for all stakeholders in the film and television industries to contribute to a better understanding of the challenges to health and well-being faced by those working in these industries - and establish best practices to address them.

• Industry Stakeholders are also potential ‘partners for change’ and include, but not limited to:

• Individuals who collectively work in the industry
• Union and Guilds and their Members
• Production companies
• Studios
• Funders and Financiers
• Professional Organizations and Advocacy Groups
• Film Schools
• State and Federal government agencies (i.e. OSHA)
• Freelance workers
• Industry Vendors (i.e. craft services, equipment rental, etc)
• University Research Institutes
• Insurance companies
• Law Firms
• Casting companies
• Specific Stakeholders invested on health and safety

• This document uses a public health framework for assessing and proposing positive change to the industry.

• This is a living document and new contributions, suggestions and edits are welcomed.  

• Appendix A. Best Practices for Reforming the Screen Industry Culture

• Appendix B. Industry Health Statistics

Introduction

Just as film and television productions follow a script, schedule and a methodology, public health initiatives utilize a theoretical framework and a method of investigation to comprehensively assess the workplace, understand the problems, and propose potential solutions.

By applying fundamental public health principles to improve working conditions in the film and television industries, all stakeholders can create a healthier, more fulfilling work environment for today’s creators—and build a safer, more equitable workplace for the next generation of aspiring technicians and storytellers.

Some definitions:

Health: “A state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (World Health Organisation, 1948)

Safety: can be considered “protection from harm, risk, or threat to one’s health”.

Health equity: is the state in which everyone has a fair and just opportunity to attain their highest level of health. Health disparities are preventable differences that populations experience in the burden of disease, injury, violence, or opportunities. (CDC)

Thriving from Work: is the state of positive mental, physical, and social functioning in which workers' experiences of their working conditions enable them to thrive in their overall lives, contributing to their ability to achieve their full potential in their work, home, and community.

Determinants of Health: the range of personal, social, economic, and environmental factors that influence health outcomes. Some are modifiable, and contribute to overall health in varying degrees (estimated below as percentages).

What follows is an exploration of these determinants in more detail, as they relate to the film and television workplace. Tools for Assessment along with possible Interventions are explored.

1. Physical Environment

When considering modifiable physical environmental determinants of health within the film and television industry workplace, we recognize that there are industry-specific factors that contribute to the unique and often unpredictable nature of production environments. Here’s how these factors play out specifically for film and TV workers:

Potential interventions to address physical environmental risks

• Develop a “Set Safety Plan” in Pre-Production prep tailored to each production - and not just for stunts
• Mandate a Health & Safety (HS) &/or Wellness officer access or presence on location
• Enforce OSHA (or local equivalent) compliance for temporary worksite locations
• Adopt “Green Production” standards that also address crew health (e.g., idling limits, air filters)
• Provide “cool-down” or “warm-up” stations for extreme weather settings
• Make hydration, sun protection, and ergonomic training standard onboarding topics
• Explore Total Worker Health® approaches that combine safety with wellness initiatives

2. Clinical Healthcare Services

The table below outlines modifiable determinants of health related to clinical healthcare services for film and television workers, with a focus on access, quality, and workplace-specific challenges. These suggestions reflect both on-set care and the broader health system interface film professionals engage with—especially given the irregular hours, freelance status, and high physical and psychological demands.

Potential Interventions for Improved Healthcare Access

• Industry Partnerships: Create preferred provider networks or contracts with on-demand services familiar with production demands and do not rely on insurance reimbursement
• Union & Guild Action: Enforce health service standards in collective bargaining agreements (IATSE, SAG-AFTRA, DGA)
• Data & Reporting: Track health utilization patterns, injuries, and gaps in service across productions to inform policy
• Education & Engagement: Offer digital wellness briefings or health optimization consults tailored to the cast, crew freelance lifestyle
  

3. Health Behaviors: The Six Pillars of Health

The American College of Lifestyle Medicine (ACLM) defines the six pillars of health as key evidence-based lifestyle practices—nutrition, physical activity, restorative sleep,avoidance of risky substances, positive social connections, and stress management —that together promote optimal health and prevent or reverse chronic disease.

Potential Interventions for Encouraging Healthy Behaviors

Broader System Interventions for Supporting Healthy Behaviors

Policy-Level Interventions:

• Enforce regulated work/rest cycles and meal breaks in union contracts
• Include wellness language in production safety manuals and job descriptions

On-Set Infrastructure:

• Provide healthy catering, filtered water, and rest spaces
• Designate wellness liaisons or mental health first aiders on large sets

Health Promotion Initiatives:

• Offer crew wellness consults (e.g., nutrition, sleep coaching, stress check-ins)
• Develop mobile apps or crew portals for tracking wellness, sleep, and fitness

Cultural Change:

• Recognize burnout and fatigue as hazards and as financial cost risks
• Celebrate wellness role models on set (e.g., producers or leads modeling healthy behaviors)

4. Socio-Economic Determinants

Below is a tailored framework addressing the socio-economic determinants of health as they apply to film and TV workers. These cultural determinants shape health outcomes by influencing workers’ access to resources, stability, and opportunity—and they are particularly important in an industry marked by freelance labor, wide income disparities, and geographic and employment unpredictability.

Potential Socio-Economic and Cultural Interventions

Policy & Contractual Mechanisms

• Include portable benefit systems and minimum guaranteed work hours
• Require all productions to submit health equity impact assessments
  

Employer/Production-Level Practices

• Offer income continuity tools (e.g., union “benefits bank”)
• Create “wraparound services” including wellness, mental health, housing, and food assistance for freelancers

Union & Guild Leadership

• Advocate for legislative protections for freelance and gig workers
• Fund training programs that prioritize underrepresented voices and skill advancement

Community & Advocacy

• Partner with non-profits to deliver social services, job readiness, and emergency assistance
• Build peer-led support networks to address isolation and share resources
  

A Socio-Economic Health Equity Pyramid

Measuring the Impact of Interventions Across Multiple Determinants of Health

To assess, measure, monitor and compare the impact of interventions, consider examining each determinant of health, or more broadly a holistic approach.  SetMD is planning the use of a validated questionnaire to measure the impact of interventions - Harvard University's (Thriving From Work Questionnaire FAQs).

It is a standardized assessment tool, available as a Short-form (8 items) Questionnaire and a Long-form (30 items) Questionnaire measures across six domains:

1. Work-related emotional and psychological well-being
2. Social well-being from work
3. Work-life integration
4. Job design and experience of work
5. Basic needs for thriving
6. Health, physical and mental well-being

A Framework for Change Already in Use in Other Industries

Total Worker Health® approach to Workplace Well-being

The Total Worker Health® (TWH) framework is a comprehensive approach developed by the National Institute for Occupational Safety and Health (NIOSH) that integrates workplace safety and health promotion into a unified strategy. Rather than treating safety and wellness as separate efforts, TWH recognizes that the conditions of work significantly influence overall health outcomes—and that optimizing both safety and well-being leads to better productivity, satisfaction, and long-term health.

Core Principles of Total Worker Health

According to NIOSH, the Total Worker Health approach includes:

• Leadership commitment to worker safety and well-being at all levels.
• Design of work that eliminates or reduces workplace hazards and promotes well-being.
• Worker engagement through participatory practices in program planning and evaluation.
• Supportive policies and practices that improve both working conditions and employee health.
• Data-driven decision making using health metrics and injury tracking to refine programs.

In industries like healthcare, construction, and manufacturing, TWH has led to:

• Reduced injury rates
• Improved chronic disease outcomes
• Higher job satisfaction and retention
• Enhanced mental health and resilience
• In the film and TV industry, adapting TWH might mean:
• Safer production environments (e.g., better air quality, rest policies)
• Wellness programs that support nutrition, mental health, and sleep
• Systems to reduce burnout, injury, and long-term harm

Conclusion Improving the health and safety of film and television workers requires a framework grounded in health optimization, disease prevention and health equity. Through coordinated policy, workplace design, access to care, support for healthy behaviors, and socio-economic resilience, we can build a sustainable, thriving creative workforce for today and tomorrow.

Acknowledgments Thanks to Dr. Susan E. Peters, Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Dr. Gregory R. Wagner, Department of Environmental Health, Harvard T.H. Chan School of Public Health and other individuals from industry unions and guilds, health professionals, production professionals, and wellness advocates who helped inform this document.

References by Organization

• World Health Organization
• CDC
• OSHA
• NIOSH
• American College of Lifestyle Medicine
• Harvard Center for Work, Health, and Well-being
• Additional References and recommended Reading

APPENDIX A.

Industry Health and Safety Statistics

Looking Glass Report 2024 (Film and TV Charity, UK)

• 35% of respondents rated their mental health as "poor" or "very poor" (up from 24% in 2022; worst in series).
• 30% experienced suicidal thoughts in the past 12 months (higher than national average of ~5%).
• 30% scored high on loneliness (up from 24% in 2022; UK national average ~8%).
• 52% often feel lonely at work (UK worker average ~20%).
• 63% said work negatively affects their mental health.
• 41% experienced bullying, harassment, or discrimination in the past 12 months (down from 46% in 2022; ~2.5x national average of 16%).
• 53% of those who experienced bullying/harassment/discrimination did not report it.
• 64% considered leaving the industry due to mental health concerns (up from 60% in 2022).
• 79% had financial worries in the past 12 months (up from 63% in 2022).
• 15% were workless (tripled from 5% in 2022).
• 18% worked 50+ hours in the prior week (down from 33% in 2022).
• 12% view the industry as a mentally healthy place to work.
• Freelancers (74% of respondents): 38% poor mental health (vs. 32% permanent); 32% suicidal thoughts (vs. 22%); 85% financial worries (vs. 61%).
• Disability/long-term condition (26%): 53% poor mental health (vs. 29% without); 50% suicidal thoughts (vs. 23%).
• Neurodivergent (27%): 46% poor mental health (vs. 30% neurotypical); 51% bullying (vs. 36%).

Hollywood Commission Entertainment Industry Survey (2022-23)

• 82% aware of unacceptable workplace behaviors (up from 76% in 2020).
• 74% know how to report concerns (up from 68% in 2020).
• Only 31% believe a powerful harasser would be held accountable.
• 41% would not report misconduct because they believe nothing would be done.
• Reporting rates remain low: ~28-32% to supervisor/HR/legal (similar to 2020).
• Women aged 25-39: 3x more likely to experience unwanted sexual attention than men in the same age group.
• LGBTQ+ respondents: 17% experienced unwanted sexual attention (vs. 3% heterosexual); 19% discrimination (vs. 7% non-LGBTQ+).
• Workers with disabilities: Almost 2x as likely to experience bullying; 17% judged incapable (vs. 7% without); higher sexual harassment rates (e.g., 41% unwanted sexual attention vs. 29%).
• Black workers: 18% denied jobs due to skin tone (vs. 2% White).
• Independent/low-budget productions: Higher vulnerability (e.g., 21% denied opportunities vs. 15% on large studios; double rates of sexual coercion and assault).
• Belief in progress on preventing harassment: 80% White cisgender men (vs. 62% others).
• Retaliation after reporting: Increased 21-33% from 2020-2023 (e.g., 17% called "difficult to work with").

Impact of Injury '24 (Injury Prevention Consultancy, IPC)

• 85% of respondents said they or a colleague had been injured at work.
• 79% personally injured.
• Cast injury rates: 82%; crew: 79%.
• In theatre: 85% of performers injured; 89% said job demands exacerbated injuries (higher than screen sectors at 67%).
• 69% believe creative vision is prioritized over safety.
• Only 7% always feel safe voicing safety concerns (4% in theatre; 11% in screen).
• Impacts of personal injury: Stress (45%), anxiety (38%), pressure to work through injury (36%).
• 12% of injuries prevented acceptance of future work.
• 61% of screen workers performed unsafe material; 16% injured as a result.

Demanding Dignity Behind the Scenes (2022, UNI Global Union)

• Average working day: 11+ hours (plus prep/wrap, totaling 12-13 hours).
• Weekly hours: 40-50+ (often exceeding legal limits; common 50-60+ hours).
• Overtime: 41% frequent during the week; 35% always required.
• Weekend work: 41% common; 18% always required.
• 25% said overtime was not paid at premium rates.
• 62% said work schedules negatively impact mental wellbeing.
• 28% in independent TV reported grave accidents from fatigue.
• UK Bectu survey: >90% sometimes feel unsafe due to tiredness; nearly 90% negative effect on family life.
• Long hours (55+ per week): 35% higher stroke risk; 17% higher heart disease mortality.

“People want better” Qualitative Study (2024)

• 84-90% experienced a mental health challenge (vs. 65% general population).
• 55% considered taking their own life.
• 83% believed industry culture negatively affects wellbeing.
• 93% experienced or witnessed bullying/harassment.
• 62% said long hours (12-13 average) negatively impact mental wellbeing.
• 80% believed working hours negatively impact health/wellbeing.
• 95% experienced childcare difficulties.
• 80% witnessed mistakes due to fatigue.
• 90% felt unsafe on set/travelling due to tiredness.
• Up to 75% believed line managers need more training in people/management skills.

REFERENCES (APPENDICES A and B.)

Advocacy Groups

1. Film and TV Charity: - https://filmtvcharity.org.uk/ Associated report: Looking Glass Report 2024 (download: https://filmtvcharity.org.uk/assets/documents/Reports/LOOKING_GLASS_REPORT_2024.pdf)
2.  Injury Prevention Consultancy: https://www.thisisipc.com/ Associated report: Impact of Injury '24 (download: https://www.thisisipc.com/s/IPCIOI24REPORT.pdf)
3. Mark Milsome Foundation: https://www.markmilsomefoundation.com/
4. 6ft From the Spotlight: https://6ftfrom.org/
5. Raising Films: https://www.raisingfilms.com/
6. Hollywood Commission: https://www.hollywoodcommission.org/ Associated report: Hollywood Commission 2022-23 Entertainment Industry Survey (download: https://static1.squarespace.com/static/6099a7247693533fc5285016/t/659f6e3719ebc112811060af/1704947267688/hc_surveyreport_2023_12.pdf)

Unions and Guilds

7. UNI MEI (UNI Global Union's Media, Entertainment & Arts sector): Official website - https://uniglobalunion.org/ Associated report: Demanding Dignity Behind the Scenes (2022) (download: https://uniglobalunion.org/wp-content/uploads/uniglobal_behindthescenes_en_final.pdf)
8. SAG-AFTRA: https://www.sagaftra.org/
9. IATSE: https://iatse.net/
10. Equity (Actors' Equity Association): https://actorsequity.org/ 

Governmental Agencies

11. OSHA (Occupational Safety and Health Administration): https://www.osha.gov/
12. Department of Labor: Official website - https://www.dol.gov/ 

Other Stakeholders in the Film Industry

13. Ethics & Compliance Initiative: https://eci-insights.com/
14. “People want better” qualitative study (2024): Full article access - https://www.tandfonline.com/doi/full/10.1080/17482631.2024.2326681
15. [Quiet] Safety on Set - student thesis (2025, Drexel University): Access page - https://researchdiscovery.drexel.edu/esploro/outputs/graduate/Quiet-safety-on-set-a-study/991022098342904721