Summary

ABSTRACT The agriculture, forestry, and fishing sectors are the cornerstone of industries that produce and market food, fiber, and fuel. Collectively, the three sectors make up a huge component of the U.S. economy and are a major employer in the United States. Annually, these industries generate more than $1 trillion and create exports exceeding $68 billion. The National Institute for Occupational Safety and Health (NIOSH) estimates that more than 5.5 million workers are employed in agriculture, forestry, and fishing. These sectors also consistently rank in the top six most hazardous occupations; fishermen and loggers have the highest fatality rates. Collectively, the three sectors consistently have the highest injury and fatality rates of any U.S. industries, so the overall effect on the safety and health of exposed populations in agricultural, forestry, and fishing worksites is enormous.

In conjunction with planned reviews of up to 15 NIOSH research programs, the National Research Council convened a committee of experts to review the NIOSH Agriculture, Forestry, and Fishing Research Program (AFF Program) to evaluate the relevance of its work to improvements in occupational safety and health and the impact of NIOSH research in reducing workplace illnesses and injuries. Relevance was evaluated in terms of the priority of work carried out and its connection to improvements in workplace protection. Impact was evaluated in terms of its contributions to worker safety and health. The committee was also asked to assess the program’s identification



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Summary ABSTRACT The agriculture, forestry, and fishing sectors are the corner- stone of industries that produce and market food, fiber, and fuel. Collectively, the three sectors make up a huge component of the U.S. economy and are a major employer in the United States. Annually, these industries generate more than $ trillion and create exports exceeding $68 billion. The National Institute for Occupational Safety and Health (NIOSH) estimates that more than 5.5 million workers are employed in agriculture, forestry, and fishing. These sectors also consistently rank in the top six most hazardous occupations; fishermen and loggers have the highest fatality rates. Collectively, the three sectors consistently have the highest injury and fatality rates of any U.S. in- dustries, so the overall effect on the safety and health of exposed populations in agricultural, forestry, and fishing worksites is enormous. In conjunction with planned reviews of up to 5 NIOSH research pro- grams, the National Research Council convened a committee of experts to review the NIOSH Agriculture, Forestry, and Fishing Research Program (AFF Program) to evaluate the relevance of its work to improvements in occupa- tional safety and health and the impact of NIOSH research in reducing work- place illnesses and injuries. Relevance was evaluated in terms of the priority of work carried out and its connection to improvements in workplace protec- tion. Impact was evaluated in terms of its contributions to worker safety and health. The committee was also asked to assess the program’s identification 

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a g r i c u lt u r e , f o r e s t r y , fishing research niosh and at  and targeting of new research areas, to identify emerging research issues, and to provide advice on ways the program might be strengthened. Although responsibility for controlling workplace exposure to agricul- tural, forestry, and fishing safety and health hazards lies with others, the AFF Program can be expected to contribute to efforts to reduce the effects of these workplace hazards through its research and information dissemination. Tak- ing into account several important factors beyond the program’s control, the committee found that from 990-006 (the period covered by this review), the AFF Program has made meaningful contributions to improving worker safety and health in agriculture, forestry, and fishing. Using a five-point scoring scale (where 5 is highest), the committee con- verted its assessment of the relevance of AFF Program research into a score of 4 because research has been in high-priority and priority research areas, and research has resulted in some successful transfer activities. The committee ar- rived at this score after considerable deliberation: research carried out in some subprograms was more relevant than in others, and the program has been somewhat engaged in transfer activities, but not always the most appropri- ate. Had the committee been given the option of providing non-integer scores, the score for program relevance most likely would have been between 3 and 4. In addition, there was little evidence that the research activities, outputs, and intermediate outcomes contributed to the stated end outcomes of reduc- ing workplace injury and illness. For this reason, the committee assigned the research program a score of 3 for impact, indicating that research program activities are ongoing and outputs are produced, which are likely to produce improvements in worker safety and health. To enhance the relevance and impact of its work and fulfill its stated mis- sion of providing national and world leadership to reduce workplace hazards through a focused program of research and prevention, the AFF Program should foster effective leadership to create a cohesive program, establish stra- tegic goals, implement a comprehensive surveillance system that identifies and tracks worker populations at risk, engage stakeholders for input on research priorities, develop new approaches for technology and information dissemina- tion, and incorporate current national developments in its targeting of new and emerging research areas. STUDY PROCESS The committee was charged with reviewing the AFF Program, evaluating the relevance of its work to improvements in occupational safety and health, and evalu- ating its impact on reducing workplace illnesses and injuries. As suggested in the statement of task, the committee’s review was guided by the Framework Document

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summary 3 (Appendix A) that was developed by the National Academies’ Committee for the Review of NIOSH Research Programs. The review of the AFF Program was based in large part on written materials provided by NIOSH (see Appendix C). Information gathering included presentations by NIOSH staff and other invited guests in open sessions of committee meetings in January and March (see Appendix B). To evaluate the research program’s work in its entirety, the committee chose to evaluate it from its inception in 1990 to the most current timeframe in 2006. In 1990, Congress directed NIOSH to develop an extensive agricultural safety and health program in surveillance, research, and intervention to address the high risks of injuries and illnesses in agricultural workers and their families. The Con- gressional Agricultural Occupational Safety and Health Initiative applies directly to activities in agriculture, but timber harvesting and commercial fishing-related activities are implicitly included. CHARACTERISTICS OF AN IDEAL AFF RESEARCH PROGRAM As its first step in evaluating the NIOSH AFF Program, the committee was di- rected by the Framework Document to independently identify the major program challenges for an occupational safety and health research program in agriculture, forestry, and fishing. When considering the ideal research program, the committee focused its efforts on identifying the following program components that would comprehensively and effectively address the safety and health issues that face work- ers in agriculture, forestry, and fishing: • Identify and engage stakeholders, • Identify populations at risk, • Conduct surveillance, • Conduct health effects research, • Conduct intervention research, • Conduct health services research and training, • Conduct research on knowledge diffusion and technology transfer, • Inform public policy and provide regulatory assistance, • Conduct program evaluation initiatives. The committee used the ideal program as a benchmark to measure the goals and activities of the existing NIOSH AFF Program. AFF PROGRAM GOALS The ideal NIOSH AFF Program would have adequate resources to set priorities among and accomplish the congressionally stated goals of surveillance, research,

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a g r i c u lt u r e , f o r e s t r y , fishing research niosh and at 4 and intervention through (1) identification and characterization of injuries and ill- ness and detailed characterization of populations at risk through surveillance; (2) identification and characterization of special populations and the unique health and safety risks they face; (3) identification and characterization of health effects associated with chemical, physical, and biological agents encountered in agricul- ture, fishing, and forestry; (4) identification, development, evaluation, and imple- mentation of control systems to reduce injury and illness; and (5) development of efficient and effective outreach mechanisms for dissemination and delivery of knowledge developed through research. ASSESSMENT OF RELEVANCE AND IMPACT On the basis of information provided by NIOSH and others and its own experi- ence and expertise, the committee assessed the degree to which the AFF Program has led and carried out research most relevant to improvements in workplace pro- tection in agriculture, forestry, and fishing. The Framework Document provides a scale for rating program relevance and impact (Box S-1). The committee also con- sidered external factors in scoring for program relevance and program impact. Resources have been inadequate for the AFF Program to carry out its con- gressional mandate in the area of agriculture, let alone in the additional areas of forestry and fishing. In contrast with other NIOSH programs that focus research on narrow sectors and well-defined problems, the AFF Program has the task of addressing manifold issues that affect the occupational safety and health of nearly all natural resource workers on land and sea. NIOSH non-sector based programs address extremely narrow topics and can focus good science on well-defined prob- lems, whereas the AFF Program is expected to spread its resources to address broad issues, so it is difficult to conduct research on all of them. In agriculture, the AFF Program responded in a reasonably effective manner to the extreme diversity that characterizes agricultural production in the United States. The extensive sectoral, technical, and geographic diversity of the agricultural industry left NIOSH with no alternative but to focus on key subjects. Despite those enormous challenges, the AFF Program has proved that it is able to conduct sound research on focused areas when given the opportunity. That is the case with the Alaska commercial fishing program, which is an exemplary research program with concentrated research topics, clear goals, and adequate resources. Work on agricultural risks to respiratory health conducted by AFF Program staff in collaboration with other researchers has included cutting-edge research that has moved the field forward. Several factors contributed to these successes: research that was focused and targeted, use of clear and consistent surveillance methods, involve- ment of key stakeholders, and motivated core staff to ensure project continuity.

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summary 5 BOX S-1 Scale for Rating Program Relevance and Impact Rating of Relevance 5 = Research is in highest-priority subject areas and highly relevant to improvements in workplace protection; research results in, and NIOSH is engaged in, transfer activities at a significant level (highest rating). 4 = Research is in high-priority subject area and adequately connected to improvements in workplace protection; research results in, and NIOSH is engaged in, transfer activities. 3 = Research focuses on lesser priorities and is loosely or only indirectly connected to workplace protection; NIOSH is not significantly involved in transfer activities. 2 = Research program is not well integrated or well focused on priorities and is not clearly connected to workplace protection and inadequately connected to transfer activities. 1 = Research is an ad hoc collection of projects, is not integrated into a program, and is not likely to improve workplace safety or health. Rating of Impact 5 = Research program has made a major contribution to worker health and safety on the basis of end outcomes or well-accepted intermediate outcomes. 4 = Research program has made a moderate contribution on the basis of end outcomes or well-accepted intermediate outcomes; research program generated important new knowledge and is engaged in transfer activities, but well-accepted intermediate out- comes or end outcomes have not been documented. 3 = Research program activities or outputs are going on and are likely to produce improve- ments in worker health and safety (with explanation of why not rated higher). 2 = Research program activities or outputs are going on and may result in new knowledge or technology, but only limited application is expected. 1 = Research activities and outputs are NOT likely to have any application. NA = Impact cannot be assessed; program not mature enough. The NIOSH Centers for Agricultural Disease and Injury Research, Education, and Prevention (Ag Centers) are an invaluable component of the AFF Program and have contributed to its successes. The Ag Centers serve as a national resource for addressing agricultural safety and health problems through research, education, prevention, and intervention. The regional nature of the centers allows research to be focused, targeted, and relevant to U.S. worker populations. The centers are based in university settings, enabling researchers to draw on university resources. Over-

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a g r i c u lt u r e , f o r e s t r y , fishing research niosh and at 6 all, the Ag Centers have methodically carried out and encompassed the necessary components of an occupational safety and health research program: surveillance, research in various subject areas, partnerships and collaborations with state and local stakeholders, and information dissemination. Nearly one-third of the research conducted by the AFF Program was conducted through the Ag Centers, and the centers have strategically addressed issues that affect various populations. Relevance The committee assigned the AFF Program a score of 4 for relevance because it found that research has been in high-priority and priority subject areas, and research has resulted in some successful transfer activities. The AFF Program has engaged in some high-priority research areas and has done an adequate job of addressing major problems. A number of relevant, effective, and important research and intervention pieces have resulted from the program. As previously mentioned, the work on Alaska commercial fishing has focused on highly important issues and has had an impact. The Childhood Agricultural Injury Prevention Initiative is extremely relevant, and some evaluations of the North American Guidelines for Children’s Agricultural Tasks have shown reduced injuries when the guidelines were applied. The National Agricultural Tractor Safety Initiative is another example of a focused research effort that has been extremely relevant. Research on musculoskeletal disorders that assessed simple and direct solutions for agricultural worker populations is an important issue that was ad- dressed and that had a direct impact on workers. The research conducted on injuries and respiratory diseases is notable, even though efforts were somewhat disjointed at times. The AFF Program’s current collaboration with other federal agencies on the Agricultural Health Study is a crucial endeavor that addresses the effects of environmental, occupational, dietary, and genetic factors on the health of the agricultural population. Although the AFF Program has been engaged in some high-priority research, it has not balanced its research efforts to reflect areas that merit the highest priority. Forestry work remains one of the deadliest occupations in the United States, but the AFF Program has yet to demonstrate substantial effort in this area outside of Alaska and the Southeastern United States. The committee is concerned that the AFF Program is not in tune with modern agricultural and forestry practices, lacks the ability to review efforts and know when to move on to other emerging issues, and consequently NIOSH does not have an accurate grasp of issues most pressing to agriculture and forestry workers. As seen in information provided to the com- mittee, the AFF Program has struggled to conduct surveillance to identify subjects that warrant the highest priority for attention and has not been able to accurately

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summary  define the populations that it serves. It has also struggled to effectively engage stakeholders to identify current issues and to disseminate its research findings to practice. Those are important matters that affect the kinds of research conducted; leaving them unaddressed will severely hinder the AFF Program’s ability to conduct research relevant to worker safety and health. The AFF Program is engaged in transfer activities, but it has not been entirely successful in developing integrated approaches to disseminating research findings so as to yield additional reductions in injuries and illnesses in the AFF sectors. The AFF Program does not appear to be as heavily involved in translational research activi- ties as it should be. Where it is involved, it does not always appear to know how and to take credit for that involvement. The outreach approaches that do exist tended to have been developed in other industrial settings and have not been appropriate or effective in reaching most target AFF populations; industrial settings differ dra- matically from AFF worksites and workforce, and different approaches are needed to reach worker populations in the AFF sectors. Many examples of such models have been used by the Ag Centers and are described in Chapter 8. As previously mentioned, some projects have been successful in outreach because they first and foremost successfully engaged stakeholders and target populations and understood how to translate research results into workplace practices. The AFF Program has been ill equipped, even among university-based and clinical researchers, to address cultural and language barriers. Bench scientists can- not be expected to become instant experts in unfamiliar cultures, foreign languages, and rural lifestyles or practices. Several first-rate scientists have courageously and frankly admitted their lack of expertise and experience in community outreach and have asked for assistance in public conferences that involved the AFF Program. Impact The committee concluded that AFF Program activities or outputs are going on and are likely to produce improvements in worker health and safety, and gave the AFF Program an impact score of 3. That score was merited by the fact that the program has made some contributions to worker safety and health, as seen in the success of projects that have affected children, commercial fishermen, and tractor operators. But the committee had a difficult time establishing a clear record of positive impacts because the AFF Program itself has not given much priority to documenting the impact of its efforts. In some instances, the committee was aware of impacts that could be attributed to the AFF Program for which the program itself did not take credit. In other cases, however, it is clear that the contributions of the program have not been accepted by stakeholders nor has the research pro- gram engaged sufficiently in transfer activities. The committee concluded that the

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a g r i c u lt u r e , f o r e s t r y , fishing research niosh and at 8 impact of the AFF Program’s research has been hampered by a lack of leadership, stakeholder buy-in, and effective dissemination of knowledge and practices. The committee finds that the NIOSH AFF Program has made important contribu- tions that are likely to produce improvements in worker safety and health. The outputs of the AFF Program include a wealth of information that is still considered current and important by the scientific community. However, the information has not been organized in a manner that is understandable by or helpful to others and has not been accessible to its own researchers; the AFF Program holds great potential for impacting workers if it is able to organize information in an accessible, under- standable, and helpful format. Research has informed public policy and regulatory initiatives at the federal level and in several states. It is vital that independent, scientifically based research continue to inform policy and regulatory discourse. Many in the AFF industries are well aware that safety and health are woven into the fabric of successful businesses. As illustrated by the tragic loss of life associated with the recent sinkings of fishing vessels off New Bedford, important gaps still allow extremely dangerous conditions to continue. NIOSH has a unique role as the only federal agency capable of convening all players dedicated to preventing workplace injury and disease, and it has deployed itself credibly on this task and funded other partners to function in consensus- building roles. NIOSH-sponsored symposia and workshops have had a great impact on the work of many occupational safety and health professionals and prob- ably on the lives of AFF workers, but it is difficult to measure the direct impact of these indispensable capacity-building activities on worker safety and health. The AFF Program has made important contributions to occupational health services and training endeavors across the nation. The committee members them- selves have benefited from NIOSH-sponsored meetings and symposia, which have sparked the interest of occupational safety and health practitioners and provided others with valuable avenues for professional growth that would otherwise not have been available. It remains vital that NIOSH continue such support because it has singular influence in convening clinicians, scientists, and training institutions; con- ducting clinical research that produces occupational training insight; prescribing appropriate content for occupational training; and providing scientific and clini- cal evidence that informs practice standards. But there is room for improvement. For example, there is a need for physicians to become more involved in preparing training materials and to enroll in training courses. In light of the growing numbers of schools of public health, there is a need to prepare appropriate education and training curriculum materials for health professionals. The AFF Program evidence package and supplemental materials lacked substan- tial data demonstrating any substantial changes in the annual number of occupational fatalities or disabling injuries in hired farm workers and several other populations.

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summary 9 The lack of data may be attributed in part to the failure to conduct surveillance comprehensively and to poor data management and collection. There was also a lack of evidence of concerted efforts to address hazards, safety, and health in for- estry workers and in fishermen outside of Alaska. Worker populations have not been adequately defined or tracked; therefore injuries and illnesses and changes in these populations have not been documented. The AFF Program’s unfamiliarity with standard sources of data on hired farm- worker employment, including the long-established USDA quarterly Farm Labor, is an indication of its inability to obtain accurate denominator data for its sepa- rate populations. The program has not used state-level data and data from other sources, such as workers’ compensation insurance coverage, that contain a rich body of information on hired farmworker morbidity and mortality that would be valuable in informing discussions of changes in rates of occupational injury or illness. Key Program Limitations Although on the whole the AFF Program demonstrated success in addressing some relevant issues and showed that it had impacted some populations, the com- mittee identified limitations that affected the program’s progress and effectiveness. The committee observed several issues that affected both the AFF Program’s ability to conduct research on issues relevant to AFF workers and its ability to conduct research that would have an impact on worker safety and health. Leadership and Strategic Planning The overarching concern about the AFF Program is the lack of a single cohesive vision to drive the research agenda. The lack of consistent leadership, long-term strategic planning, and periodic review of that course has led to a piecemeal ap- proach to the research program, and the program appears disjointed more often than not. However, the patchwork approach has produced some successful efforts because of the efforts of talented and dedicated researchers. Surveillance The AFF Program appears to have had considerable difficulty in applying the principles of and engaging in surveillance. Constraints to successfully imple- menting comprehensive surveillance may be due to external factors and funding. Basic demographic and health effects surveillance of each human population at risk of worksite exposure is essential because without it no effective targeting of

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a g r i c u lt u r e , f o r e s t r y , fishing research niosh and at 0 other programmatic elements can occur, nor can one know when an intervention has been effective and move on to address other priorities. Surveillance must be broad-based in its population targets inasmuch as the sector is diverse in settings and employment practices and places that put populations at risk, such as children, wives, and the elderly. Stakeholders On the basis of the information provided by the AFF Program, remarks pro- vided by stakeholders, and comments submitted by the public, the committee un- derstands that the AFF Program has not fully engaged its stakeholders. It has had some remarkable partnerships to reach stakeholders, such as those with the com- mercial fishing industry in Alaska, but it has struggled to engage other stakeholders. The program has met the most success when it has understood stakeholder needs by asking for direct feedback from farm workers, loggers, and fishermen. It has also garnered the most credibility when researchers have demonstrated that they are sensitive to stakeholder needs, which vary greatly among the three sectors. Without a strong buy-in from its targeted populations, the program may ap- pear to be out of touch with its stakeholders and unresponsive to the realities of the workplace environment, and its work may therefore not be credible among farm workers, loggers, and fishermen. Stakeholders have also at times confused NIOSH with the Occupational Safety and Health Administration (OSHA); most workers are more familiar with OSHA’s role in the workplace than with NIOSH’s research. Populations at Risk The AFF Program targeted specific populations that it deemed at higher risk than others but omitted certain other populations and fell short in defining the entire population of AFF workers at risk of injury and illness. There has yet to be a program-wide endeavor to characterize the numbers and types of workers involved in agriculture, forestry, and fishing. Some populations, such as hired farm workers, have also been poorly defined or miscategorized, and others, such as ranchers, have been largely unaddressed. IDENTIFYING EMERGING ISSUES AND RESEARCH AREAS The committee was charged with assessing the program’s targeting of new research in occupational safety and health most relevant to future improvements in workplace protection. It was also asked to identify emerging issues important

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summary  for NIOSH and the program. In keeping with the guidance of the Framework Document, the committee provided suggestions on the basis of the expertise of individual members rather than as a product of a formal process to explore and synthesize recommendations that could be developed through a comprehensive review of the field. AFF Program’s Identification of New Research Areas and Emerging Issues The AFF worksite of tomorrow clearly will be different from the worksite of today, given trends in agriculture that will affect forestry and fishing. The changes, both predicted and unpredicted, will fuel the need for surveillance of such human factors as worksite organization and management, climate, technology, and policy change and of economics. On the basis of information provided by NIOSH, the committee concludes that the AFF Program has not developed a consistent process for identifying new research issues and developing a way to address emerging issues. The success of a public health research program is marked by its ability to recognize and address the needs of a targeted population. Because the AFF Program on the whole has struggled to conduct surveillance to understand the current needs of its worker populations, it is unable to forecast future needs. In light of the fact that the program lacks an established procedure for assessing emerging issues in agriculture, forestry, and fishing, the committee furthermore concludes that the AFF Program has fallen behind in understanding current prac- tices and how these practices can create new hazards for workers. The program has instead focused resources on issues that have already been resolved by changes in work practices and environments. Thus, the AFF Program has not kept up with emerging issues and has lost the capability to gain useful knowledge and to respond with appropriate new technologies. A few projects, however, have more successfully identified emerging issues and conducted research to address them. The fishing projects in Alaska and the farm- resident child-injury initiatives, for example, have consistently carried out sound research practices to affect fishermen and children, respectively, and have been able to identify new and emerging issues for these populations. Emerging Research Needs Identified by Evaluation Committee In evaluating the AFF Program’s research, the committee identified several kinds of research missing in health effects, health services, intervention, and regu- latory policies (Chapter 11). Some research issues that have not been investigated are of great relevance to improvement of AFF worker safety and health and could substantially affect safety and health with help from NIOSH.

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a g r i c u lt u r e , f o r e s t r y , fishing research niosh and at  BOX S-2 Recommendations for Program Improvement Establish Strategic Goals for Improvement in Administration and Evaluation Recommendation 1: The AFF Program should establish strategic goals for the overall program and for separate subpopulations to provide a basis for improving program leadership, administrative oversight, and program evaluation. 1.a: The AFF Program lacks a concerted effort and should focus its administrative efforts on improving program leadership, administrative oversight, and program documentation. 1.b: The AFF Program should develop a comprehensive program evaluation mechanism to assess and set priorities among its research and transfer activities. Develop a Cohesive Program Recommendation 2: The AFF Program should provide national leadership and coordination of research and transfer activities in agricultural, forestry, and fishing safety and health. Implement a Comprehensive Surveillance System Recommendation 3: The AFF Program should implement a comprehensive surveillance system. Identify and Track AFF Populations at Risk Recommendation 4: The AFF Program should clearly identify and track its target populations. 4.a: A clear definition of worker populations “at risk” is needed. 4.b: The AFF Program should conduct comparative studies across agriculture, forestry, and fishing to better set priorities and to respond to dynamic workforce and workplace conditions. Conduct Research on Knowledge Diffusion Processes Recommendation 5: NIOSH should conduct research on the science of knowledge diffusion to identify effective methods for AFF research-to-practice programs. RECOMMENDATIONS FOR PROGRAM IMPROVEMENT The AFF Program is the sole federal research program dedicated to enhancing the safety and health of workers in agriculture, forestry, and fishing. As such, the AFF Program should be the definitive leader and source of expertise in occupa- tional safety and health in agriculture, forestry, and fishing. From its evaluation of

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summary 3 5.a: The AFF Program should incorporate broader social science expertise into the research diffusion process. 5.b: The AFF Program should explore communication tools capable of reaching the AFF workforce. Improve Stakeholder Engagement and Partnerships Recommendation 6: The AFF Program should establish a new model to involve stakeholders throughout the research process, and should also establish an effective multipartite stakeholder mechanism that in- cludes at-risk workers and other organizations to focus on occupational safety and health. 6.a: The AFF Program should develop a new model for targeting all key stakeholders as full participants in its research program design and execution. 6.b: The AFF Program should establish a coordinating council that would serve as a public advisory com- mittee and would assume lead responsibility for informing public discourse on occupational safety and health issues. 6.c: The AFF Program should continue to partner with appropriate federal and state agencies and estab- lish additional interagency partnerships to increase the capacity for carrying out research and transfer activities. 6.d: The AFF Program should establish public-private partnerships to work more closely with equipment, facility, and pesticide manufacturers in design and development processes. Implement Integrative and Interdisciplinary Approaches Recommendation 7: The AFF Program should implement integrative and interdisciplinary approaches in its research practices. 7.a: Researchers that receive funding from the AFF Program should visit worksites regularly so that they can acquire understanding of the workplace environment and thus develop and integrate culturally ap- propriate and sensitive approaches. 7.b: The AFF Program should increase the use of interdisciplinary teams to address the environmental, social, cultural, and psychological complexities of issues that face AFF workers. Enhance Awareness of National Policy Recommendation 8: The AFF Program staff should develop greater awareness of national policy activities because they can have a substantial impact on AFF worker populations and risk factors. the relevance and impact of the program (Chapter 10) and its assessment of new and emerging research (Chapter 11), the committee identified several potential opportunities to improve the relevance of the program’s work and strengthen its impact on reducing injuries and illness in the AFF sectors. The committee’s rec- ommendations are aimed at improving the program as a whole (summarized in Box S-2):

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a g r i c u lt u r e , f o r e s t r y , fishing research niosh and at 4 • Establish Strategic Goals for Improvement in Administration and Evaluation • Develop a Cohesive Program • Implement a Comprehensive Surveillance System • Identify and Track AFF Populations at Risk • Conduct Research on Knowledge Diffusion Processes • Improve Stakeholder Engagement and Partnerships • Implement Integrative and Interdisciplinary Approaches • Enhance Awareness of National Policy The AFF Program plays a positive and crucial role in providing information and tools to promote a safer and healthier work environment in agriculture, for- estry, and fishing. The committee hopes that its recommendations will help refocus and redirect program efforts to have a greater impact on the safety and health of all populations at occupational risk in agriculture, forestry, and fishing.