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9 Other Programmatic Elements Identified by the Committee In following the components of the committee’s ideal Agriculture, Forestry, and Fishing (AFF) Program, the committee identified other elements that the program has been involved in and provides here a review of engagement with stakeholder constituents, health services research and training, public policy and regulatory advice, and program evaluation initiatives. STAKEHOLDERS The AFF Program seeks to engage stakeholders in its work, and the challenges in engaging such a large and diverse workforce are obviously great. Other National Institute for Occupational Safety and Health (NIOSH) programs also have an array of stakeholders, but AFF stakeholders—the program’s ultimate beneficiaries—are an extraordinarily diverse constituency. Most of the 2 million-plus AFF businesses are small and are operated by self-employed persons assisted by family members, including children. Increasing numbers are immigrants from Mexico and Southeast Asia who produce specialty crops on small-scale farms. Self-employed workers who provide the majority of the labor in their operation seek to earn their fami- lies’ livelihoods in outdoor environments, sometimes enduring hardships that few U.S.-born workers would tolerate. 40

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o t h e r P r o g r a m m at i c e l e m e n t s i d e n t i f i e d committee by the 4 AFF Workers The AFF workforce consists of those earning their livelihood in the AFF sector and is diverse in race, ethnicity, language, culture, class, and social norms. The bulk of the workforce is made up of hired workers, and many are employed only on a seasonal basis. Large portions of AFF hired and contract workers are low-literacy, non-English speaking immigrants, many of whom are not authorized to work in the United States: in fisheries, increasing numbers are of West African or East Asian ori- gin; in agriculture, the vast majority are from Mexico or Central America. Language barriers are becoming greater as more and more hired and contract workers speak languages lesser known in the United States, such as Triqui, Mixtec, Zapotec, Maya, Purépecha, and Quechua; at least a dozen languages are spoken daily on U.S. farms, and most do not have a written form. Efforts to engage these populations must overcome barriers of language, culture, race, ethnicity, and class. Underlying the challenges of engaging AFF workers is the deep-seated division between those who seek immediate practical solutions to their problems and those in the research community who prefer to engage in contemplation or laboratory experimentation. The historical foundation of that divide in our society has been well described by Hofstadter in Anti-intellectualism in American Life (1963). Com- pounding the barrier is the low level of scientific literacy among workers that the AFF Program seeks to engage. One might say that the reverse is also true: that the schism between the intellectuals and the workforce is perpetuated by a failure of the intellectuals to communicate effectively on workers’ terms, taking into account different work circumstances and cultural attitudes. Finding common ground or even a meeting space comfortable for all parties may be difficult. The following pages describe four instances in which efforts to overcome barriers were successful to the benefit of all parties. The examples illustrate ap- proaches, not recipes, that AFF projects could adopt or adapt. Engaging Hired Farm Laborers In 1988, the Ford Foundation challenged the California Institute for Rural Studies (CIRS) to undertake research in the subject of farm labor and rural poverty in California. The challenge included a requirement that academics, laborers, and community leaders meet and develop a collaborative agenda. A meeting place had to be found in which all parties would be comfortable. The bias of the CIRS staff in selecting a meeting space was that a university or college setting would probably be inappropriate because relatively few farm laborers had ever attended college or felt comfortable among highly articulate experts. In the end, a modest motel with suitable meeting rooms near downtown Fresno was selected. That choice was made because Fresno is in the center of the San Joaquin Valley, the most productive agri-

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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 cultural region in the United States, employing over 200,000 farm laborers during spring and summer. Fresno is a community that many farm laborers visit and in which they were likely to feel comfortable. Some academics were uncomfortable with the choice because it meant leaving the familiar confines of their campuses, such as Berkeley, Santa Cruz, and San Diego. However, when the reason for the choice was carefully explained, nearly all 60 faculty members invited to participate expressed appreciation for the thought that had gone into the selection process. For the 60-odd farm labor representatives or rural community leaders, who included industry representatives, the choice of Fresno made sense from the beginning. Next, the conference discussion process involved carefully choosing eight aca- demics to prepare research papers on specific topics: housing, voting rights, labor relations, the California farm labor market, measuring rural poverty, indigenous migrants, the changing structure of agriculture, and pesticide policy. At the conference, the presentation of papers was structured so that a panel of three would comment on each paper—typically an academic, a farm labor repre- sentative or rural community leader, and an industry representative. Papers were provided to panel members at least a week in advance of the conference. Time was allotted for comments or questions to any of the panelists. A panel facilitator and note-taker kept the entire process running smoothly, and simultaneous translation into Spanish and English was made available to all who needed such assistance. Among the outcomes of the conference were eight conference proceedings papers, with synopses of panelists’ or conference participants’ comments, and the formation of a project advisory committee to provide general guidance to the CIRS staff in its work. All the labor and community participants found the format to be welcoming and to have enhanced participation. Engaging Hired Forestry Services Workers The second example involved the U.S. Department of Agriculture (USDA) Forest Service, which in California had found that its staff was relatively unin- formed about Hispanic immigrant workers, many of whom were showing up as contract laborers for planting or other work on federal land. In 1995, CIRS was contacted by a representative of the Forest Service who asked whether it might be possible to set up a workshop to enable staff members to learn more about the newest components of the forest labor force. In the view of CIRS staff, it was essential that Forest Service personnel en- counter Spanish-speaking immigrant workers directly, not just hear a description of them in English. CIRS staff arranged for a busload of about 50 Forest Service employees to visit a public farm labor camp near Stockton. The meeting was held in the evening, after the workday, after the workers had a chance to change from

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o t h e r P r o g r a m m at i c e l e m e n t s i d e n t i f i e d committee by the 43 work clothes into more comfortable attire, and after everyone had a chance to get an evening meal. A local Spanish-English interpreter was recruited, and four cur- rent farm laborers volunteered to participate in a panel presentation for the Forest Service employees. The gathering was held outdoors under a rooftop mat with benches arranged in a semicircle facing the panel of workers. Several dozen other farm laborers and family members also attended, mostly out of curiosity. The panel presentation was enlightening. The four workers described their home villages, how they came to the United States to find work, how many years they had been coming to the United States to work in the fields, how much they earned, how much money they sent back home each week to support their families, and what they thought about while doing heavy manual labor in the baking hot fields of the San Joaquin Valley. One worker said that he wanted to learn more about the potential impacts of the newly approved North American Free Trade Agreement on employment in his region of Mexico. Forest Service employees asked many eye-opening questions. One worker described how he had been coming to the Stockton area for over 45 years, doing the same kind of work year after year, and how his grandson had just graduated from California State University, Stanislaus, with an honors degree in computer sciences. He said he was proud that his labor had helped to make it possible for his grandson to realize his dream. After he spoke, there were several moments of silence among all participants in the evening’s event and then a crescendo of respectful applause. Engaging Northern High Plains Growers The third example involved growers on the northern high plains. In 1998, or- ganic growers in central North Dakota requested a meeting with scientists of the National Farm Medicine Center (NFMC) so that they could explore concerns about personal health and about potential contamination of their organic farm products resulting from the use of pesticides on adjacent acreage that had been purchased or rented by potato growers of the Red River Valley in the North. The organic growers could smell the pesticides used by potato growers and wondered about exposure of themselves or their households. The use of the products is not permitted on organic acreage, and the organic growers were concerned that pesticide drift would contaminate growing crops, the soil in which the crops are grown, or worse, the hands, feet, face, and other body parts of people working on organic acreage. North Dakota is administratively in federal HHS Region IV, so NFMC con- tacted the High Plains Intermountain Center for Agricultural Health and Safety (HICAHS) at Colorado State University, Fort Collins; the two centers worked together to structure a 2-year study of the issue. Once institutional review board

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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 44 approval was secured, scientists of both centers requested face-to-face meetings in the separate household living rooms of organic growers and potato growers so that basic study outlines could be reviewed and both communities might experi- ence buy-in. Each group was wary of the other (and the local county agricultural extension agent warned explicitly against any form of study), so engaging both on their individual turf was the first step in a long process of gaining mutual cred- ibility. The participatory research provided greater buy-in to the proposed study and its potential findings (McCauley et al., 2001; Quandt et al., 2001; O’Fallon and Dearry, 2002). Scientists of both agricultural centers listened intently on site to group descrip- tions of agricultural operations and tasks performed by workers; wore the requisite plastic booties while on the “walk-abouts”; walked farmsteads and fields; had coffee and home-baked delicacies in farm kitchens, living rooms, and local restaurants; and ended several rounds of meetings by noting the availability of a federal partner who had the field-collection instruments and advanced laboratory capability that a study of this type demanded. Neither protagonist was enthusiastic about inviting a federal partner, but both reluctantly agreed to permit NIOSH to enter the proposed study as a partner and to accompany NFMC and HICAHS scientists when study procedures were launched. Private resources from NFMC were used to fund the study, inasmuch as both agricultural groups were suspicious of any form of federal funding involvement. Numerous meetings and less formal interactions with both groups of growers ensued on their premises, always in the local community. At no time was it expected that either group would travel to Marshfield, Wisconsin, or Fort Collins, Colorado; rather, scientists and technicians from the agencies went to the study areas. And no one from either agricultural group travelled to Cincinnati, Ohio, or Morgantown, West Virginia, to engage scientists at NIOSH directly. The study was launched with perimeter air sampling around organic crop acreage, the farmsteads of organic growers, and selected “control” areas elsewhere. As data collection proceeded, technical staff were invited to provide study updates and transmit educational information about the study, pesticide products used on potato crops and their potential human health effects, types and hydrological characteristics of soil overlying aquifers in central North Dakota, and the use of personal protective equipment. NFMC scientists and technical staff invested ad- ditional effort to educate potato growers about preventing nontarget exposure, applying pesticide with “best management practices”, and planning for the future use of integrated pest management strategies. In less than a year, NIOSH staff members were viewed as legitimate partici- pants on the study team and were included in all activities when on site. Initial study results were presented to both agricultural groups in fall 1999 (Gunderson

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o t h e r P r o g r a m m at i c e l e m e n t s i d e n t i f i e d committee by the 45 et al., 1999). The settings for these disclosures were the living room of an organic grower, a local meeting room for potato growers, and a local hunting lodge for study staff of all three agencies. Study results were surprising to both groups of growers (Gunderson et al., in review), but both indicated that they were impressed by the fairness with which they were treated; by the tenacity of both technicians and scientists in attempting to learn what happens in production agriculture settings, why it happens, and who is potentially affected; and by the lack of arrogance and “pretty urban talk” on the part of staff and scientists. Engaging Alaska Commercial Fishermen The fourth example, from commercial fishing, can be found in the work leading to the publication and distribution of the booklet Deck Safety for Crab Fishermen (Jensen Maritime Consultants, 2002), a publication that is in its third printing since its release in 2002. The NIOSH Alaska Field Station had determined that crab fishing in Alaska was an extremely high-risk industry. By reviewing the injury data available, NIOSH researchers found that most injuries aboard crab vessels were associated with the pot launcher, the bait chopper, and slips and falls. The researchers then sought out and interviewed a group of crab fishermen for ideas on safety improvements. Once the NIOSH team had formulated a list of safety improvement sugges- tions, it vetted them by surveying 89 crab fishermen associated with 75 boats of different types and sizes in Dutch Harbor, Alaska. By getting their boots wet and actively seeking to engage the stakeholders in the targeted industry, NIOSH vastly improved the validity of its proposed interventions. By also having contacted about 36 percent of the crab-fishing fleet, NIOSH laid the foundation for buy-in by a very individualistic population. The product that it developed generated so much interest that some of the stakeholders published the booklet themselves instead of waiting for NIOSH’s long internal review process. A consistent and often-repeated theme throughout the committee’s information-gathering meetings was that NIOSH serves its stakeholders best when it follows a “boots on the ground, get dirty” approach to research and reaches out to its constituents. NIOSH has enjoyed its greatest successes through nimble, targeted, and adaptive efforts that are conducted in a timely manner. Non-Workers as Stakeholders Another category of stakeholders consists of those who interact with and serve AFF worker populations. These stakeholders provide support services and include equipment manufacturers, various government agencies (USDA, the Na-

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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 46 tional Cancer Institute, the National Institutes of Health, the National Institute of Environmental Health Sciences, state departments of agriculture, the Cooperative Extension Service, and state and local health agencies), veterinarians, agricultural engineers, and state and local agencies that provide essential services, such as healthcare providers and forest firefighters. But engaging those additional stake- holders would supplement, not substitute for or in any sense replace, the engage- ment of directly affected workers. The committee here distinguishes between the working population directly engaged in AFF production and people engaged in support activities, including research. As mentioned in Chapter 2, NIOSH needs to consider five types of directly affected stakeholders in each of the agriculture, forestry, and fishing sectors: self- employed workers, unpaid family workers, direct-hire workers, contract-hire work- ers, and workers employed by larger-scale businesses. Other persons may be at risk owing to their living on or adjacent to worksites because AFF workplaces are, by their relationship to natural resources, extensive as opposed to localized. The ad- ditional persons may include children, spouses, or other relatives of AFF workers. The National Children’s Center for Rural and Agricultural Health and Safety has been effective in reaching out to and engaging all five categories of workers, albeit with considerably greater success among some categories than others. The fishing program in Alaska has been particularly effective in directly involving various cat- egories of workers in addressing occupational safety in a localized fishery industry; however, some categories of workers may have been underrepresented. Organizations representing self-employed and unpaid family workers in agri- culture are relatively highly developed, especially nowadays with the proliferation of commodity-based groups; there is relatively effective involvement of some of these groups in the AFF Program, as was clear at the Seattle National Occupational Research Agenda (NORA) session in January 2006. Despite those successes, both hired and contract workers have been underrepresented throughout the brief history of the AFF Program. The fault is by no means to be placed only on the program, as there are substantial barriers to engaging hired and contract workers, including language and cultural gaps. Compounding the problem is the relative absence of involvement of most hired and contract workers in any organization that directly represents workers. Labor unions represent only a very small fraction of hired and contract farm workers—no more than 30,000 of a national hired workforce estimated to be of 1.3-2.25 million workers (Villarejo and Baron, 1999). The record of labor unions in the AFF sector is spotty: some have had a strong commitment to making the workplace safer, but others have demonstrated little interest in this issue. The American Federation of Labor and Congress of Industrial Organizations’ Department of Occupational Safety and Health has recognized that “NIOSH is valuable in that it can address new, unregulated hazards such as ergonomic problems” (Factor and Uehlein, 1990).

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o t h e r P r o g r a m m at i c e l e m e n t s i d e n t i f i e d committee by the 4 Nonprofit advocacy groups and government-funded service agencies have occupied the front lines in seeking to represent hired and contract workers. Al- though some efforts have been helpful, few of the spokespeople who speak on behalf of hired and contract workers have any direct experience as AFF workers themselves or, in some cases, only slight direct contact with these workers. Direct worker involvement as stakeholders is essential if their views are to be adequately represented. Stipends need to be considered to compensate workers for time off of work and travel expenses. HEALTH SERVICES RESEARCH AND TRAINING Health services research is defined as the multidisciplinary field of scientific inves- tigation that studies how social factors, financing systems, organizational structural processes, health technologies, and personal behaviors affect access to healthcare, the quality and cost of healthcare, and ultimately health and well-being. The research domains of this field are individuals, families, organizations, institutions, communi- ties, and populations. Health services research examines how people obtain access to healthcare, how much healthcare costs, and what happens to patients as a result of this care. The goals of health services research are to identify the most effective ways to organize, manage, finance, and deliver high-quality care and improve patient safety (Academy Health, 2000). This research has been conducted to study a variety of healthcare aspects, including those pertaining directly to occupational health. Health services research has not been conducted in as much detail in agricultural, forestry, and fishing workers as in other occupational groups. The term training refers to the education of professionals in specific topics directly related to safety and health. It may target people working as or training to become nurses (including advanced practice nurses), physicians, physician’s assistants, physical therapists, occupational therapists, mental health counselors, emergency medicine technicians, lay health workers, safety professionals, engi- neers, and industrial hygienists. At times, the training has been specific to clinical problems that are directly relevant to AFF workforce safety and health issues and has been conducted with a public health approach; however, at other times, it has been a general approach to occupational safety and health without emphasis on problems seen in AFF workers. There has been a consistent approach to educating healthcare professionals about AFF occupational issues. Strategic Goals and Objectives The briefing information provided by NIOSH did not contain goals pertaining directly to health services research and training. However, NIOSH funds several

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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 48 extramural projects that revolve around health services research or training and numerous extramural projects of which health services research or training is an important part. From 1990-2006, NIOSH funded up to 16 Education and Research Centers (ERCs) across the United States. Many ERCs offer education and training for medical providers, safety professionals, and others who work with agricultural health and safety issues. NIOSH describes the emphasis as follows: “The core areas of programming are industrial hygiene, occupational health nursing, occupational medicine, and occupational safety. Programs are developed to meet the educational needs of these groups as well as other professionals working in the field of occu- pational safety and health” (ERC, 2007). In addition, NIOSH has funded at least one program to train lay health advisers, also called promotoras. The ERCs provide training programs in agriculture, forestry, and fishing. Inputs The main inputs to health services research, education, and training have been NIOSH funds distributed to the agricultural research centers (ARCs) and the ERCs, although the committee is aware that NIOSH clinicians and scientists have provided faculty expertise to the centers. University-affiliated centers have also been major contributors to the programs that have been developed with faculty and staff outside the centers as well as those hired with ERC funds. The documentation provided by NIOSH is unclear on the role of the private sector. For example, the Mary Imogene Bassett Hospital—affiliated with the New York Center for Agricultural Medicine and Health—has been instrumental in launching studies of respiratory, auditory, and musculoskeletal problems faced by farmers; the study results have been used in the design of new outreach capacity and in clinical training. The Marshfield Clinic of Wisconsin fielded similar outreach and training activity. NIOSH documentation, however, does not mention such efforts. Collaborations with and contributions from other local and regional community medical facilities are likely to have been critical for the success of such initiatives. Documentation of them was difficult to find in the materials provided by NIOSH for use by the committee. Activities Most of the health services research and training activities were reported for the agricultural sector; very few could be found for forestry and fishing. A number of the health services research and training programs in agriculture are specifically designed to offer health or safety training directly to farmers or farm workers in addition to educating medical or safety professionals. That dual approach to edu- cation is desirable for the entire sector.

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o t h e r P r o g r a m m at i c e l e m e n t s i d e n t i f i e d committee by the 49 Agriculture The NIOSH-funded ERCs at selected academic institutions (some of which also have Ag Centers) have funded projects related to production agriculture, in- cluding training in industrial hygiene, occupational health nursing, occupational medicine, and occupational safety. For example, the ERC at the University of Iowa has funded postdoctoral fellows who engage in training in a wide variety of top- ics. It is less clear whether there is a formal relationship between the NIOSH Ag Centers and the ERCs or whether collaborations evolved through opportunity. It is also not clear how much emphasis is placed on agricultural health in each ERC program. However, the committee has observed that numerous professionals have been encouraged to explore occupational health issues—explorations that probably would not have taken place without the presence of ERC initiatives. Quantifying the training might be useful to measure the adequacy of preparation for practice and as a means of determining whether NIOSH funds are well spent. Examples of health services training in agriculture are summarized below. Promotores de Salud From 1999 to 2003, AFF Program researchers at the Uni- versity of Illinois at Chicago developed and evaluated an intervention to reduce the number and severity of eye injuries in Latino farm workers through collabora- tion with peer health advisers (promotores de salud) in Illinois and Michigan. The promotores de salud were trained in eye injury and first aid by AFF Program staff. Contacts with workers focused on distributing protective eyewear and on train- ing in the importance of wearing appropriate eyewear. Data were collected on the effectiveness of the intervention and showed that use of appropriate protective eyewear by Hispanic farm workers can be increased by training lay health advisers to select and custom-fit protective eyewear acceptable to workers and by providing the eyewear for distribution by the promotores (Migrant Health Promotion, 2005). The research group established an eye health and safety Web site in collaboration with the Rural Women’s Health Project to disseminate information about eye injury prevention and the project nationally. Certified Safe Farms The Certified Safe Farms program (funded largely by NIOSH) has been active at the University of Iowa for about 12 years. Collaborating academic institutions have included the University of Nebraska Medical Center. The project is designed to determine whether farm safety inspections and resulting changes in safety practices, with health screening of farmers, will reduce injuries and costs of farm families’ healthcare. Participants receive occupational health screenings, health and wellness education, on-farm safety reviews, and incentives for adopting safer farming processes. Willing farmers work with a nurse trained in farm safety and health and a person trained in inspecting farms for safety hazards.

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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 50 Variations of the health screening and farm inspection process have been developed for different forms of production agriculture in the Midwest. Self-reported data pertaining to the costs of occupational injury and illness paid by participants and their insurers were collected. Healthcare Provider Training Several universities that have medical schools— such as the University of Illinois, the University of Iowa, and the University of Minnesota—have received funding from NIOSH to design and implement oc- cupational health training programs for physicians, nurses, and other healthcare providers and persons who do not have a healthcare background in agricultural health. The programs are well established and use AFF Program resources to extend work to neighboring states. Although the programs have responded to the obvi- ous need for training, the committee notes that the programs would benefit from greater physician input in course content and clinical approach. Occupational Health Nurses in Agricultural Communities (OHNAC) From 1990 through 1996, the AFF Program funded 31 public health nurses in rural com- munities in 10 states (California, Georgia, Iowa, Kentucky, Maine, Minnesota, New York, North Carolina, North Dakota, and Ohio) to conduct case-based, and some- times rate-based, surveillance. In 1995, the program funded continued surveillance under the banner of Community Partners for Healthy Farming Surveillance. States that were funded under the original OHNAC project and later funded by Com- munity Partners for Healthy Farming Surveillance usually retained OHNAC in the titles of their programs. The surveillance projects addressed multiple agricultural subsectors. For simplicity, both surveillance projects will usually be referred to hereinafter as OHNAC. Northwest Community Health Worker Network Extramural AFF Program re- searchers engaged the Hispanic farmworker community through two community- based participatory research projects in Washington and Idaho. Together with the Washington Association of Community and Migrant Health Centers, researchers established the Northwest Community Health Worker Network and listserv, and they provided professional education to clinicians and trained community health workers in prevention and diagnosis of and treatment for pesticide poisoning. Take-home Pesticide Exposure Study The primary purpose of the take-home pesticide exposure study conducted by the University of Washington was to de- scribe the sources of pesticide contamination in farm homes and investigate the relationship between clinically documented contamination and pesticide exposure of family members in the home. A combination of environmental and biological

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o t h e r P r o g r a m m at i c e l e m e n t s i d e n t i f i e d committee by the 5 sampling was used. Questionnaires and on-site observation were used to determine practices and behaviors that may contribute to exposure and thereby to provide content for future professional education venues. Forestry Before formal implementation of the AFF Program in 1990 but concurrently with congressional adoption of appropriations legislation establishing the program in NIOSH, NIOSH provided National Traumatic Occupational Fatality Surveil- lance System data to support development of an Occupational Safety and Health Administration (OSHA) forestry standard. It also gave OSHA recommendations about including multiple safe felling techniques, making changes in the snakebite section of the standard, improving work-area organization and communication, using rollover protective structures (ROPS) and falling-object protective struc- tures (FOPS), and prohibiting some unsafe harvesting techniques. In 1994, OSHA adopted the final standard, which incorporated most of the recommendations made by NIOSH; the recommendations spanned several of the research domains of the health services research arena. Fishing NIOSH conducted an early assessment of the decline in commercial fishing deaths on the Alaskan shelf after implementation of the Fishing Vessel Safety Act in 1991. It found that although deaths had decreased, vessel sinkings had not. In addition, NIOSH identified the fishery in which each fatal event had occurred. The crab fishery in the Bering Sea was shown as the most hazardous fishery in Alaska and the problem was the loss of fishing vessels, which meant loss of life. In 1997, NIOSH convened other partners at the second national Fishing Industry Safety and Health (FISH II) Workshop in Seattle to develop practical recommendations that would prevent vessels from sinking. It resulted in the Preseason Dockside Inspection Program, implemented by the U.S. Coast Guard beginning in 1999. That program appears to be highly effective in reducing deaths, thereby probably reducing the use of clinical care, but at this time it is limited to the Gulf of Alaska and the Bering Sea. Outputs The AFF Program has produced numerous projects related to health services that would probably not have existed without the program. The OHNAC program, initially funded by NIOSH in 1991-1996, has generated noteworthy findings and

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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 5 publications, which are all the more remarkable because NIOSH did not formu- late epidemiologically derived guidance for nurses “in the field” that might have resulted in more precise targeting of efforts to the highest-risk agricultural worksite exposures in the 10 funded states. Outputs of the OHNAC program included peer- reviewed publications targeting clinicians and others, which form the backbone of formal instructional materials (including clinical texts); continuing education updates; self-study courses; simulations; and seminar content. Overall, the output of the AFF Program has been substantial in health services research and training, although less than output of other kinds, such as informa- tion aimed directly at workers. At times, a lack of planning and organization has hampered progress. It is not always clear how conducting health services research and training fits with the other missions of the NIOSH AFF Program. Other Outcomes There is evidence that some NIOSH-funded health services research projects may be influencing industries tangentially related to the AFF sector and to the topic of occupational safety and health. Those industries span a continuum from liability insurance carriers to equipment manufacturers—such as those producing tractors or fishing vessel cable winching devices—to health and safety product vendors. The influence of NIOSH can be detected in the marketplace: from the presence of safety-enhanced end-user products to the belief by the insurance industry that use of these products reduces occupational injury and illness. The reductions may occur because of the effect on worker social factors, sector development of financ- ing incentives, changes in organizational work-setting procedures and supervision, introduction of new and improved technologies for prevention of ill effects or their timely clinical detection, or adjustments in how basic medical care is de- ployed. And the projects have enhanced the professional development of classically trained agricultural engineers, industrial hygienists, safety professionals, industrial nurses, and so on whose career trajectories evolved from full-time employment in sector-related industry to university-based Ag Centers, occupational health clinics, and other private venues, such as the National Safety Council. Examples of these outcomes include the following: • The Certified Safe Farms project has received funding from the health insurance industry in Iowa. This may be an important first step in reaching the ultimate goal of making preventive health services available to farmers. • In 1997, extramural AFF Program staff at the University of Iowa sponsored consensus-building activity, including a capstone conference to develop an ap- proach to implementing a nation-wide tractor-related injury and death prevention

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o t h e r P r o g r a m m at i c e l e m e n t s i d e n t i f i e d committee by the 53 program. That initiative has spawned other activity in several communities—the farming, engineering, clinical, and occupational health research communities; federal agencies; and state legislatures. These communities have addressed tractor- related issues through the use of ROPS on tractors through public incentives; improving lighting and marking to reduce injuries and deaths due to collisions between tractors and motor vehicles on public roadways; enhancing the train- ing of basic and advanced emergency medical technicians in clinically efficacious methods of victim extraction and scene stabilization; exploration of emergency machine-stopping mechanisms; and promulgation of designs for safe play areas for children and adolescents near or in agricultural work zones. PUBLIC POLICY AND REGULATORY ADVICE At its formation, OSHA was designated to be the federal agency with primary responsibility for regulation and enforcement of workplace safety. NIOSH was created as an independent, scientific research organization to inform the public, including governmental agencies, about occupational health and safety, and to play an advisory role in recommending ways to reduce risk of injury or illness in the workplace. However, NIOSH has regulatory authority for respirator certification in agricultural environments for confined spaces and for dust and pesticide exposure (42 CFR Part 84). Those are the only direct regulatory roles of NIOSH. The Crucial Role of NIOSH The committee finds that the AFF Program has played a central role in im- proving public oversight of occupational safety for the AFF workforce at both the federal and state levels. The committee also finds that the NIOSH Ag Centers, owing to their specific regional focus, have made important contributions to informing public policy discourse. The AFF Program has provided both research findings and advice for a number of substantial modifications of workplace safety regulation. It has also initiated several important partnerships to develop improvements in occupational safety. The two most notable partnerships have been with the Alaska commercial fishing industry, where NIOSH engaged the industry workforce directly, and with the Childhood Agricultural Safety Network, where a brilliant example of coalition building was successfully undertaken and realized over a period of years. The AFF Program has conducted 16 investigations as part of the agency-wide Fatality Assessment and Control Evaluation (FACE) program. Those efforts were not regulatory, but they identified deaths of young workers who were assigned tasks prohibited by hazardous order regulations and incidents in which non-English

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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 54 speaking workers were not provided with appropriate training. Such scientific, non-regulatory studies contribute knowledge that underpins regulatory advice. Less visible but important have been the efforts of some of the separately funded regional NIOSH Ag Centers. For example, Pacific Northwest Agricultural Safety and Health (PNASH) Center research efforts have led to invitations to center faculty to participate in national policymaking discourse. The Western Center for Agricultural Health and Safety has engaged county health departments in Merced and Fresno Counties, California, regarding current research initiatives of interest. Several researchers presented policy briefings at the California state capitol to a large audience of legislative staff and advocacy groups (Villarejo and Schenker, 2005). Other centers similarly have engaged local and regional agencies and private organizations and trade groups in policy discussions. NIOSH core staff continuously engaged federal agencies in policy discourse. For example, NIOSH staff met with USDA Forest Service representatives concern- ing issues ranging from the use of insect repellents by Forest Service staff to cleanup policies regarding the use of safe cleaning agents. Also notable are the multiple re- search contributions that inform proposed new hazardous orders for child workers in agriculture and ergonomics standards to address repetitive-stress disorders. Barriers to Effective Use of NIOSH Policy and Regulatory Expertise Although NIOSH is uniquely positioned to provide independent, scientifically founded information and advice to inform public policy and regulatory discourse, several barriers may severely limit its contributions. First, as the NIOSH evidence package notes, the AFF workforce is to a great degree unregulated. The various stat- utory exemptions from the Fair Labor Standards Act and the Occupational Safety and Health Act, noted in Appendix F, severely limit the purview of NIOSH research activities; OSHA, for example, excludes all farms with 10 or fewer employees. Second, and perhaps decisive in the current regulatory regime, there is a strong preference in some agencies for allowing market forces to shape the workplace en- vironment. That preference is reflected in the sharp decline in federal occupational safety regulatory activity in recent years. Third, Congress itself has been an important barrier even to the consideration of regulatory change. As the NIOSH AFF evidence package points out, “the pro- gram has provided information to support new OSHA standards related to logging, field sanitation, air contaminants (remanded in 1992), and ergonomics (repealed in 2002) (Luginbuhl, 1997). Moreover, the program sought out other opportunities for supporting federal regulations including the Coast Guard’s implementation of the Commercial Fishing Vessel Safety Act of 1988, EPA’s promulgation and enforce- ment of the pesticide Worker Protection Standard, and Department of Labor revi-

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o t h e r P r o g r a m m at i c e l e m e n t s i d e n t i f i e d committee by the 55 sions to child labor hazardous orders. But there has been little regulatory activity in agriculture safety and health.” Legislative actions have eliminated or repealed regulations that could signifi- cantly reduce and prevent workplace injuries and illnesses in the workplace. The committee finds that congressional interventions, such as its repeal of the ergonom- ics standard adopted by OSHA (OMB Watch, 2001), appear to have been based on controversial political considerations and to have ignored compelling scientific assessments and evidence of probable adverse long-term safety and health effects on the labor force. By ignoring the best scientific advice (NRC, 1998b, 1999; NRC and IOM, 2001), such ill-advised maneuvers have resulted in missed opportunities to reduce important occupational musculoskeletal risk factors. Despite the fact that musculoskeletal injuries and illnesses are the leading cause of work limitations (Liberty Mutual, 2006), it may take years to resurrect the ergonomics standard. To further complicate matters, the repealed OSHA ergonomics standard had already excluded agriculture. Fourth, some scientists publish research findings but fail to follow through with the same urgency to seek needed improvements that their research suggested. Moreover, research scientists may lack the necessary communication skills to en- gage affected communities effectively. It is useful in this context to consider how private sector and state agency partnerships can undertake activities that are not subject to federal constraints. Private foundations, non-government organizations, industry trade groups, and others can join state agencies in undertaking initiatives to address workplace safety and health in the AFF sector, and there are numerous examples of the support of research activities by the private sector. PROGRAM EVALUATION INITIATIVES NIOSH established an Operational Logic Model with the mission “To provide national and world leadership to prevent work-related illness and injuries.” As part of this model, the goal of the AFF Program is prevention through effective research, transfer, and evaluation. Evaluation has been defined as systematic investigation of the merit, worth, or significance of the object (CDC, 1999b). This section of the report comments on the AFF Program’s evaluation initiatives as presented in the evidence package (NIOSH, 2006a) and other evaluation activities discovered during the program review. Program evaluation is extremely important for determining whether NIOSH activity has had a favorable impact on safety and health. To maximize the impact, the evaluation needs to include an analysis of the quality of the research or pro- gram. The evidence package includes a variety of evaluation activities. The 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 56 conducted by the Alaska Field Station provides a good example of continuous pro- gram evaluation consistent with the NIOSH logic model: research on commercial fishing safety is well defined and was designed by using surveillance data, which can also be used to track the outcomes of the project. Those data were also used to make changes in project activities to improve safety. The end outcome of the program is a reduction in deaths associated with fishing activities in Alaska. The Agricultural Center Evaluation Project is also a good example of a NIOSH evalu- ation initiative. The report published in January 2007 provided recommendations to NIOSH. The one overarching recommendation was to continue to support this collaborative evaluation effort. There does not appear to be a similar strategy or conceptual framework for evaluation of most AFF activities. The briefing document made it difficult to sort the information into appropriate sections in any coherent way. For example, sur- veillance discussions were scattered throughout the document, making it difficult to determine what was considered surveillance, hazard assessment, and so on. Most important, it seems that no infrastructure has been developed in NIOSH for consistently capturing the activities of AFF projects that can be used for ef- ficient, effective evaluation. The briefing book contains NIOSH’s best effort to go back and find needed information, but much of the information that must reside somewhere at NIOSH is not included; for example, the original requests for ap- plications (RFAs) for the programs launched in 1990 are not in the packet although the later RFAs calling for Ag Center applications are. The NIOSH Operational Logic Model described in the evidence package indi- cates that evaluation would occur during most of the steps of the model (Figure 1-3 on page 28 of NIOSH, 2006a). Although the evidence package does report outputs, intermediate outputs, and outcomes in many cases, there is little information on evaluating the effectiveness of the reported items. The one exception, as mentioned earlier, is the Alaska commercial-fishing project, which seems to provide evidence of effective evaluation. NIOSH staff readily admitted the difficulty of measuring outcomes. This is demonstrated in the evidence package by NIOSH stating that “in many instances it is difficult to effectively trace the contribution of NIOSH to the end outcomes. Many groups contribute to reducing occupational injuries and illnesses and to creating safer places to work. Still, NIOSH is strongly committed to developing ob- jective measures of its real-world performance. If the best measures of performance relate to motivating and enabling others to work safer, this in no way diminishes the importance of the accomplishment (NIOSH, 2006a).” Under “End Outcomes,” the evidence package notes that “evidence of reductions in occupational hazard exposures, illnesses, and/or injuries as a result of the AFF Program research is elusive at best” (page 101 in NIOSH, 2006a).

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o t h e r P r o g r a m m at i c e l e m e n t s i d e n t i f i e d committee by the 5 Many similar comments appear throughout the evidence package. One could and logically would surmise that many projects have had a favorable impact on improving the safety and health of the AFF workforce. However, the evidence package, while providing significant evidence regarding programs in place, did not document an evaluation process that could provide evidence of the overall effectiveness of the AFF Program. There is some evidence that program evaluations are conducted, but validation of program effectiveness in reducing injuries and illnesses is not robust and needs substantial improvement. A process for quantifying end outcomes and their impact on reductions in injuries and illnesses and the evaluation of programs from a quali- tative perspective needs to be established for all AFF projects. The process would be linked to surveillance and designed to provide feedback that can be used to change program priorities or activities if the present course of action is not having a sub- stantial impact. NIOSH would use a standard best-practices approach. An evalua- tion model such as the Centers for Disease Control and Prevention’s “Framework for Program Evaluation in Public Health” would be adopted and used consistently to quantitatively and qualitatively evaluate all projects and programs.