Traumatic Injury Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health (2009)

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Summary ABSTRACT Occupational injuries continue to be a significant public health problem in the United States, imposing a substantial human and economic burden. Although rates of both fatal and nonfatal occupational in- juries have declined since the passage of the Occupational Safety and Health (OSH) Act in 1970, much remains to be done. In 2006, more than 110 work- ers died each week as a result of injuries sustained on the job. According to the Bureau of Labor Statistics, in 2006, 3.9 million nonfatal injuries were sustained by U.S. workers in private-sector employment—a number that is widely recognized as a substantial underestimate. The National Institute for Occupational Safety and Health (NIOSH) is the federal agency tasked with conducting research and making recommendations for the prevention of oc- cupational injury and illness. The Institute of Medicine convened a committee of experts to review NIOSH’s Traumatic Injury (TI) Research Program. The committee evaluated the relevance and impact of the TI Research Program’s efforts for the years 1996-2005, reviewed the program’s strategic goals for the future, and provided recommendations for program improvement. Using a five-point scoring scale (where 5 is highest), the committee assigned the TI Research Program a score of 4 for both relevance and impact. The committee concluded that research was in priority areas and led to demonstrated effects on some end outcomes or on well-accepted intermediate outcomes. The committee concluded that the TI Research Program’s strategic goals for the future were focused on major  

 T r a u m a t ic I n j u r y R e s e a rc h at N I OSH contributors to occupational injuries and deaths and are sensitive to popula- tions and groups at disproportionate risk. In future iterations of its strategic goals, the TI Research Program should work toward focusing its efforts. The committee developed nine recommendations for program improvement in the areas of strategic planning, coordination and collaboration, workforce development, transfer, and the changing nature of work. INTRODUCTION In 2006, 5,840 workers—more than 110 workers each week—died as a result of injuries sustained on the job. These deaths occurred across all industry sec- tors (BLS, 2008). Nonfatal work-related injuries far outnumber fatalities and are much more difficult to count. According to the Bureau of Labor Statistics (BLS), in 2006, 3.9 million nonfatal injuries were sustained by U.S. workers in private- sector employment (BLS, 2008). More than half of these injuries required workers to transfer to another job, restrict their duties at work, or take time off from work to recuperate. These BLS estimates are widely recognized to underestimate the full extent of the problem. They exclude nonfatal injuries among the 22 percent of the workforce that are not in private-sector employment, and there is also evidence that private-sector injuries are under counted. One population-based study of work injuries (Smith et al., 2005) estimated that counts of injuries resulting in days away from work were 1.4 times higher than BLS workplace-based estimates for the private sector. NIOSH is a component of the Centers for Disease Control and Prevention (CDC), an agency of the Department of Health and Human Services (HHS). Cre- ated in 1970 by the OSH Act along with the Occupational Safety and Health Admin- istration (OSHA) in the Department of Labor (DOL), NIOSH was authorized to • Conduct research on worker safety and health, including new safety and health problems; • Develop recommendations for occupational safety and health standards; • Conduct training and employee education; • Develop information on safe levels of exposure to toxic materials and harmful physical agents and substances; • Conduct on-site investigations to determine the toxicity of materials used in workplaces; and • Fund research by other agencies or private organizations through grants, contracts, and other arrangements. 

Summary  Congress has clearly distinguished OSHA’s functions of regulation and enforce- ment from NIOSH’s research mandate. OSHA’s mission is to “assure the safety and health of America’s workers by setting and enforcing standards; providing training, outreach, and education; establishing partnerships; and encouraging continual improvement in work-place safety and health.” Charge to the Committee NIOSH has requested that the National Academies, through the National Re- search Council (NRC) and the Institute of Medicine (IOM), conduct a series of reviews of its research portfolio. This report contains a review and evaluation of the TI Research Program. NIOSH defines work-related traumatic injury as “any damage inflicted to the body by energy transfer during work with a short duration between exposure and health event.” Safety research is an interchangeable term in NIOSH publications for traumatic injury research. The TI Research Program is described by eight goal areas (Box S-1). Within each of the eight goals are two to three subgoals, with the exception of the goal for workplace violence, which does not have any subgoals. Currently, four of the TI Research Program’s efforts—agricultural injuries among children, firefighter safety, workplace violence, and workers in Alaska’s high-risk industries—are directed by congressional initiatives (NIOSH, 2007, p. 44). Using an evaluation framework developed by the National Academies Com- mittee to Review the NIOSH Research Programs, the “Framework Committee” (see Appendix A), this committee was to evaluate the relevance and impact (using an integer score from 1-5, with 5 being the highest) of the TI Research Program, as well as its future directions. (See Boxes S-2 and S-3 for more information on the scoring system.) The committee was also encouraged to provide recommendations for program improvement. The committee was comprised of 10 members and one Framework Committee liaison. The committee had expertise in the areas of occupational health, public health education, medicine, injury prevention and control, epidemiology and biostatistics, labor, industry, program evaluation, ergonomics, and bioengineering. The committee evaluated the TI Research Program for the period 1996-2005, the first decade of the National Occupational Research Agenda (NORA). The infor- mation evaluated consisted primarily of materials—organized by traumatic injury goals and subgoals—included in an evidence package provided by NIOSH to the The Framework Committee liaison is a member of the National Academies Committee to Review the NIOSH Research Programs, which is the committee that developed the framework (see Appendix A of this report) for review of NIOSH research programs. 

 T r a u m a t ic I n j u r y R e s e a rc h at N I OSH BOX S-1 Goals and Subgoals of the NIOSH Traumatic Injury Research Program a 1. Reduce injuries and fatalities due to motor vehicles 1.1.  educe occupational injuries and fatalities due to highway motor vehicle crashes R 1.2.  educe occupational injuries and fatalities due to motor vehicle incidents in high- R way and street construction work zones 2. Reduce injuries and fatalities due to falls from elevations 2.1. Reduce worker falls from roofs 2.2. Improve fall-arrest harnesses 2.3. Reduce worker falls from telecommunications towers 3. Reduce injuries and fatalities due to workplace violence 4. Reduce injuries and fatalities due to machines 4.1.  educe injuries and deaths caused by tractor rollovers by increasing availability R and use of effective rollover protective structures 4.2.  educe worker injuries and deaths caused by paper balers R 4.3.  educe injuries and deaths caused by machines through the conduct of fatality R investigations and the dissemination of prevention strategies 5. Reduce acute back injury 5.1. Reduce acute injuries caused by patient handling 5.2.  valuate interventions used to prevent acute injuries caused by material handling E 6. Reduce injuries and fatalities among workers in Alaska 6.1. Reduce injuries and fatalities in commercial fishing 6.2. Reduce injuries and fatalities in helicopter logging operations 6.3. Reduce injuries and fatalities in Alaska aviation 7. Reduce injuries and fatalities to emergency responders 7.1. Reduce injuries and fatalities to firefighters 7.2. Improve protection for ambulance workers in patient compartments 7.3.  mprove protection for emergency workers responding to large-scale disasters I and terrorist attacks 8. Reduce injuries and fatalities to working youth 8.1. Influence legislative changes to protect young workers 8.2. Reduce child agricultural injuries 8.3.  oster the development and widespread use of safety materials and intervention F strategies to protect young workers a  The numbering of the goals here is consistent with the numbering of the goals as presented in the evidence package prepared by NIOSH for the committee. The numbering is not a ranking of goals by research priority. 

Summary  Box S-2 Scoring Criteria for Relevance 5 = Research is in high-priority subject areas and NIOSH is significantly engaged in appro- priate transfer activities for completed research projects or reported research results. 4 = Research is in priority subject areas and NIOSH is engaged in appropriate transfer activities for completed research projects or reported research results. 3 = Research is in high-priority or priority subject areas, but NIOSH is not engaged in appropriate transfer activities; or research focuses on lesser priorities but NIOSH is engaged in appropriate transfer activities. 2 = Research program is focused on lesser priorities and NIOSH is not engaged in or plan- ning some appropriate transfer activities. 1 = Research program is not focused on priorities and NIOSH is not engaged in transfer activities. Box S-3 Scoring Criteria for Impact 5 = Research program has made major contribution(s) to worker health and safety on the basis of end outcomes or well-accepted intermediate outcomes. 4 = Research program has made some contributions to end outcomes or well-accepted intermediate outcomes. 3 = Research program activities are ongoing and outputs are produced that are likely to result in improvements in worker health and safety (with explanation of why not rated higher). Well-accepted outcomes have not been recorded. 2 = Research program activities are ongoing and outputs are produced that may result in new knowledge or technology, but only limited application is expected. Well-accepted outcomes have not been recorded. 1 = Research activities and outputs do not result in or are NOT likely to have any application. NA = Impact cannot be assessed; program not mature enough. committee. For its assessment of the NIOSH process for targeting new research areas and identifying emerging issues in occupational safety and health, the com- mittee relied primarily on a review of the TI Research Program’s strategic goals for the future (a list of these goals was included in the evidence package provided to the committee by NIOSH). 

 T r a u m a t ic I n j u r y R e s e a rc h at N I OSH Relevance and impact of THE ti research program The committee reviewed the work supporting the eight specific goals (includ- ing the 19 subgoals) that constitute the TI Research Program. The goals represent a mix of long-standing safety concerns (e.g., agricultural injuries), newer or emerging areas of emphasis for the TI Research Program (e.g., falls from telecommunications towers), and congressionally driven attention to important occupational risks (e.g., the Alaska Field Station [AFS]). Three goals represent specific worker populations identified by location (Alaska), age (youth), or sector (emergency response). The TI Research Program has clearly driven a national sensitivity to some specific safety problems. For example, the committee concludes that TI Research Program atten- tion to workplace violence has highlighted a previously neglected area. The committee concludes that, for the most part, the TI Research Program goals are appropriate and relevant to the burden of traumatic injury in the work- place. The burden of injury represented by the eight major goal areas is certainly high, although the committee did not attempt to independently assess the burden of injuries in all occupations or worksites in the country as part of its review. Rather, the committee understands the challenges NIOSH faces in prioritizing re- search with restricted resources and concludes that—given its limited budget—the TI Research Program has made overall appropriate selections of general areas to pursue. Although the committee concluded that many of the goal areas were high pri- ority (e.g., Alaska, falls from elevations), it identified gaps, particularly within the subgoals (falls from the same elevation; several areas within workplace violence; a narrow focus within machines). The TI Research Program engages in appropri- ate transfer activity within some, but not all, of the goal areas. In summary, the committee notes impressive work, including transfer, in priority goal areas. The committee assigns a score of 4 for the relevance of the TI Research Program. The committee commends the TI Research Program for its contributions toward reducing occupational traumatic injuries. The TI Research Program is associated with impact on either intermediate or end outcomes in each major goal. The committee recognizes that external factors—specifically, severely limited resources and inaction on the part of OSHA—can be significant barriers to the TI Research Program’s progress in some goal areas. However, the committee notes (1) the lack of demonstrated effect on end outcome data in three goal areas and in some subgoals of the other five goals; (2) the inability to determine what degree of responsibility the TI Research Program bears for the documented improvements in end outcomes or for the intermediate outcomes; and (3) a lack of significant intermediate outcomes for some subgoals. The committee assigns a score of 4 for the impact of the TI Research Program. 

Summary  Targeting New Research The second part of the committee’s charge was to perform an assessment of the TI Research Program’s effectiveness in targeting new research areas and identifying emerging issues most relevant to future improvements in workplace protection. TI Research Program project planning takes place at the research division level and at the institute level. At the division level, Division of Safety Research (DSR) staff propose research projects within the context of program drivers, which may include surveillance findings on injury incidence and severity, worker groups with the greatest numbers and risks of death or injury, congressional mandates, stake- holder input, or research needs outlined in the 1998 NORA-TI Research Program team white paper. DSR leadership—with input from staff—rates and ranks new project concepts based on project need, soundness of approach or methods, and expected impact (NIOSH, 2007, p. 43). Staff may then develop research protocols within the approved concept areas. Research protocols are peer-reviewed internally and may also be presented at public meetings for stakeholder input and to assess the interest in and potential impact of the research. According to DSR leadership, most current TI Research Program research projects are funded through the institute-wide NORA funding competition. DSR “base” funds (annual division or lab allocation) have diminished and are now used primarily for ongoing surveillance and field investigation programs, as well as congressionally mandated projects (NIOSH, 2007, p. 43). There has not been competition for new projects with DSR base funds for the past 3 years. The TI Research Program has several means by which it receives input from stakeholders on its research programs. For intramural projects, NIOSH frequently holds a public meeting announced in the Federal Register. Public meetings may be held to discuss proposed research projects that will develop or evaluate products (versus policies or procedures) that have broad stakeholder vested interest and/or are potentially controversial. The TI Research Program also organizes and hosts periodic National Occupational Injury Research Symposia (NOIRS), which bring together researchers from a broad range of disciplines to discuss research in prog- ress and to form research and prevention partnerships. Workers, advocates, and other nonresearch groups may also attend and have an opportunity to provide input regarding traumatic injury research needs. At the inception of the four TI research programs currently directed by congressional initiatives and mandates, NIOSH held stakeholder meetings to obtain input on possible research directions within these areas. Personal communication from Nancy Stout. Personal communication from Nancy Stout. 

 T r a u m a t ic I n j u r y R e s e a rc h at N I OSH The TI Research Program uses surveillance data on fatal and nonfatal injuries— primarily from the BLS surveillance systems—to identify emerging research needs. The program also has real-time access to data on injuries reported at hospital emer- gency departments through the National Electronic Injury Surveillance System, as well as data on fatal injuries in selected states through the NIOSH Fatality Assess- ment and Control Evaluation (FACE) Program, which allow for quicker detection of injury clusters and spikes (NIOSH, 2007, p. 46), as well as sentinel fatalities that identify previously unrecognized hazards. The NORA process and the relationships with stakeholders that result from it are also an important means of identifying emerging issues. In NORA, a commit- tee specifically addressed traumatic injury research needs; in the current NORA II process, industry sector councils have been formed to address sector-specific research needs. Traumatic injuries are addressed by each of these councils. The committee is sensitive to the need for the TI Research Program to choose its research activities carefully to make the best use of limited resources. Research project planning should focus on occupational risks that it has specific skills for addressing and which are not currently or better addressed by other federal or nonfederal researchers. While the committee recognizes that it is important to consider both the sever- ity and the magnitude of injury when setting traumatic injury research priorities, it is concerned that the balance of focus between fatal and nonfatal injuries is either not evident or not optimal. Based on information provided in the evidence package, it is apparent that occupational fatality surveillance data have been an important program driver. Nonfatal occupational injuries far outnumber fatal in- juries, and risk factors for fatal and nonfatal injuries are not necessarily the same. Although a focus on fatalities is reasonable in light of limited resources, this leaves a very substantial gap with respect to nonfatal injuries. Additional surveillance and surveillance research are needed to improve the characterization of nonfatal injuries (see Chapter 4 for a discussion). The TI Research Program’s draft strategic goals for the future are to (1) reduce fall injuries in the workplace; (2) reduce occupational injuries and deaths due to motor vehicles; (3) reduce occupational injuries and deaths due to workplace vio- lence; (4) reduce occupational injuries and deaths due to machines and industrial vehicles; and (5) reduce occupational injuries and deaths among high-risk and vulnerable worker groups. Within each of the five strategic goals are three or four subgoals that generally identify types of injuries, worker populations, industries, The numbering of the goals here is consistent with the numbering of the goals as presented in the evidence package prepared by NIOSH for the committee. Numbering is not a ranking of goals by research priority. 

Summary  and workplace exposures on which to focus. At the next level are intermediate goals for achieving the objectives of the goals and subgoals. Based on the expertise of its members, the committee identified areas of re- search that warrant attention in the future. Some of these are described within the context of the review of the strategic goals, and some are described in a subsequent section. Given limited staffing and budget resources, it is not expected that the TI Research Program will pursue all of the proposed research areas, but rather that it will take them into consideration. Overall, the committee finds that the TI Research Program’s draft strategic goals are focused on major contributors to occupational injuries and deaths and are sensitive to populations and groups at disproportionate risk. Among the draft stra- tegic goals are several intermediate goals for leveraging partnerships that, if carried out, could help the TI Research Program to maximize its impact a great deal. In future iterations of its strategic goals, the TI Research Program should work toward focusing its efforts (e.g., goals for motor vehicles) on areas that are not researched by other agencies or covered by other agency missions. In general, the committee also feels that future modifications to the goals could include better indication of how proposed interventions and partnerships will be evaluated. The committee identified areas of research that warrant attention in the future. Some of these are possible gaps in the five strategic goals; others are of a more cross- cutting nature. With regard to Strategic Goal 1: Reduce Falls in the Workplace, the committee was disappointed to see no obvious attention to slips, trips, and falls from the same elevation. The TI Research Program should consider including research on tribology and on risk factors for falls in older workers. The committee identified gaps in the plans for future work in motor vehicles. The committee urges the TI Research Program to consider taxi driving, short haul trucking, day delivery drivers, parking lot occupational driving, and intrastate driving. These specific areas provide opportunities for synergy (e.g., taxi drivers are at risk for workplace violence injuries and for occupational driving injuries) and fill a gap not addressed by another agency (National Highway Traffic Safety Administration researches long-haul trucking safety, but short-haul trucking is under-researched). The committee identified gaps in the goal regarding machines and industrial vehicles. The committee urges the TI Research Program to consider augmenting its future goals with research on TI injuries in the landscaping and horticultural industries, which have been identified as one of the most hazardous industries. The committee urges the TI Research Program to consider augmenting its work on vulnerable workers. The committee identified several groups of particular im- portance for the future: older workers, immigrant and minority workers, workers aged 18-24 years, and workers with developmental or physical disabilities. In addi- 

10 T r a u m a t ic I n j u r y R e s e a rc h at N I OSH tion, the committee urges the TI Research Program to extend risk factor research on vulnerable workers to include the study of informal and formal workplace policies and workplace norms and alternative work arrangements. In addition to gaps in research noted within the context of the five strategic goals, the committee identified other priority research areas that the TI Research Program could pursue in the future. These are as follows: • Organizational culture and adoption of safety measures • Cost of injuries • Policy evaluation research • Small-to-medium sized enterprises (SMEs) • Surveillance research Recommendations for Program Improvement After reviewing the evidence package provided by the TI Research Program and evaluating its work in the eight goals, the committee developed a series of general recommendations for program improvement. These fall in the general ar- eas of strategic planning, coordination and collaboration, workforce development, transfer, and the changing nature of work. A summary of the recommendations appears in Box S-4. Strategic Planning The current goal areas represent a retrofitting of a decade’s worth of work into a structure to be reviewed with the Framework Document in mind. This does not mean that considerable thought was not given by the TI Research Program over the decade to the work being done, but it is clear that some of its efforts occurred outside of and independent of a program-wide coherent planning process. The committee recognizes that opportunities arise and an agency must be adroit to deal with unexpected events (for example, the work in goal 2 regarding The TI Research Program presented its portfolio in the evidence package according to these goals in order to conform to the Framework Document (e-mail from N. Stout to K. Stratton, November 30, 2007). Prior to this configuration, the organizing structure for describing the project portfolio were three program areas that reflected (1) the four leading causes of occupational injury death (motor vehicles, machines, violence, and falls), (2) four high-risk industries (construction, trans- portation, agriculture/forestry/fishing, and services), and (3) five NIOSH/CDC crosscutting priority areas (disparities, economic impact, emergency response, NORA implementation, and emerging issues). Individual projects had relevance to one or more of the 13 elements that comprise those three program areas. 

Summary 11 BOX S-4 Summary of Recommendations Strategic Planning Continue setting goals that are within the TI Research Program’s scope and resources. Develop an explicit plan for each subgoal. Coordination and Collaboration Work with other federal agencies that support injury prevention and control research. Improve surveillance of nonfatal injuries. Work collaboratively with OSHA. Ensure collaboration among NIOSH-funded researchers. Workforce Development Increase visibility of traumatic injury research. Transfer Evaluate research-to-practice efforts. The Changing Nature of Work Research prevention strategies for traumatic injuries in a changing workplace. falls from telecommunications towers appears to be a response to a newly discov- ered occupational risk) and that there are points of departure from any planning document. Some work will appear not to fit in well with the rest of the program. This is not unexpected. With some exceptions, as discussed in Chapter 2, the program has worked in areas of public health importance and has documented intermediate outcomes. The committee concludes that the TI Research Program successes (as defined by the activities, outputs, and outcomes reviewed) have occurred most obviously in goal areas in which there was a focused and intense effort (due to resources, e.g., Alaska) or in which the goal was narrowly or clearly defined and achieve- ments could be documented. Often these areas of focus were due to congressional directives, the increased resources associated with congressional directives, and staff interest and expertise. Some of the successes arose from a focus on a newly emerging concern. 

12 T r a u m a t ic I n j u r y R e s e a rc h at N I OSH The TI Research Program should be careful in its next stage of planning and priority setting to outline as specifically as possible the scope of the work it plans to accomplish so that its achievements are demonstrably linked to a problem of importance and its research is strategic. The committee urges the TI Research Program to focus on those occupational risks that it has specific skills for address- ing and which are not currently or better addressed by other federal or nonfederal researchers. Otherwise, it risks squandering precious resources on activities that could be redundant or that will not necessarily or directly lead to accomplishing the goals of reducing morbidity and mortality from occupational traumatic injuries. 1. Continue setting goals that are within the TI Research Program’s scope and resources. Given its limited resources, the TI Research Program should continue a research focus and priority setting on goals that are well defined, are based on rigorous surveillance data, and are complementary to work being done by stakeholders, extramural research partners, or other agencies. 2. Develop an explicit plan for each subgoal. The TI Research Program should develop an explicit, written plan within each subgoal for pro- gression along the public health framework, including the circum- stances under which work in the subgoal should cease. Additional considerations should be the relative balance between risk factor and intervention research. Coordination and Collaboration Given that the TI Research Program operates under severely limited resources, it must not only be strategic in selecting its priorities, as discussed previously, but also position itself to benefit from collaborations within the federal government and with academic researchers and state agencies. These collaborations and coordi- nating activities will help the TI Research Program prioritize its activities in order to complement work elsewhere or to avoid duplication of effort. Coordination and collaboration can be achieved by several means—for example, organizational relationships and research programs. As such, the committee offers several recom- mendations that are intended to support and encourage some current collabora- tions, to identify a major new initiative, and to leverage a relationship that has perhaps recently been ignored. NIOSH is one of several federal agencies with a role in injury prevention and control, so there is obviously some overlap of agency interests, particularly with regard to research and information dissemination. In focusing on occupational traumatic injury, NIOSH should continue to foster and build relationships with 

Summary 13 other agencies, (e.g., the National Highway Traffic Safety Administration, the Na- tional Institutes of Health, the National Center for Injury Control and Prevention, the Consumer Product Safety Commission, the Department of Defense, the Health Resources and Services Administration, and the Agency for Healthcare Research and Quality). The committee encourages continued and appropriate attention to interagency issues in order to assure a unique research portfolio in the TI Research Program and the efficient deployment of scarce resources. 3. Work with other federal agencies that support injury prevention and control research. NIOSH and its TI Research Program should work with senior leadership from other federal agencies to outline areas of collaboration and synergy; to identify opportunities to further the science of injury control and prevention; and to reduce the burden of injury across populations, environments, and products. The TI Research Program has clearly been driven by a focus on fatalities. The committee understands that there are legitimate reasons to focus on fatalities and legitimate debates about aggregate burdens, but the time has come for the TI Research Program to bolster its focus—particularly starting with surveillance—on nonfatal occupational injuries without lessening the excellent work on fatal injuries. 4. Improve surveillance of nonfatal injuries. The TI Research Program should develop a plan for improving surveillance of nonfatal injuries, integral to prevention and to strengthening the TI Research Program portfolio development. A comprehensive approach should go beyond use of employer-based data to include nonemployer-based data sources such as hospital data and other medical data systems, the National Health Interview Survey, and the Behavioral Risk Factor Surveillance System. The TI Research Program should involve other relevant federal and state agencies in developing a cohesive interagency effort. OSHA is a significant external factor to the success of NIOSH research. The committee understands the difficulty NIOSH might experience in this regard. The committee urges perseverance on the part of the TI Research Program in addressing injuries and interventions of interest amenable to regulatory action by OSHA. 5. Work collaboratively with OSHA. An agency of particular importance and relevance to NIOSH is OSHA. The TI Research Program, along with NIOSH leadership, should continue to work with OSHA to iden- tify areas of high-priority research that NIOSH should undertake and 

14 T r a u m a t ic I n j u r y R e s e a rc h at N I OSH to identify NIOSH research findings of particular salience for potential regulatory action by OSHA. Members of the committee understand the tension between the needs of federal agencies and the desires of academic researchers. Academic researchers are not necessarily interested in the pragmatic questions that federal agencies need addressed. Academic researchers also tend to enjoy a degree of freedom in research settings that might not be compatible with the data or research requirements of an agency with a very narrow and directed mission. Conversely, agency priority setting activities might not allow for sufficient time for nondirected basic research in the academic setting to show relevance to agency needs. Finally, agencies often need results disseminated promptly, which is not always compatible with the timeline of the traditional academic publication process. The intramural program has obvious areas of expertise that should be used to the fullest, while new hires could be used to expand the intramural capability. The extramural research program can “fill in” what the intramural program lacks, as well as provide innovative approaches not currently anticipated or realized. However, with its limited research budget, the TI Research Program deserves and needs to fully understand the work it is supporting. Communication and collaboration are key to a successful mix of intramural and extramural research. Increased communication can also lead to increased opportunities for appropriate transfer of research findings into practice. The committee urges that this collabo- ration not be overly directed or programmed. Rather, the committee sees this as an important step in building teams for traumatic injury research. The commit- tee recognizes that there are obvious benefits to increased interactions between researchers and that NIOSH should facilitate such interactions. 6. Ensure collaboration among NIOSH-funded researchers. NIOSH should review its practices and take steps to improve the opportu- nities for intramural and extramural researchers, including state occupational public health programs, to communicate and collab- orate without excessively directing extramural research to the det- riment of scientific creativity. NIOSH should also further ensure collaboration and coordination among its programs, including the traumatic injury, construction, mining, and agriculture programs. Workforce Development Although there are no studies of this issue, the committee feels—through its own experiences and from discussions with fellow traumatic injury researchers— 

Summary 15 that it is difficult to attract new students to this very applied field. The TI Research Program needs to develop a means to increase the pipeline of traumatic injury researchers. In order to do so, the committee suggests stressing the technical exper- tise required to work in traumatic injury, the interdisciplinary nature of successful traumatic injury research, and the possibility of “making a real difference” with traumatic injury research. 7. Increase the visibility of traumatic injury research. NIOSH should embark on a program to increase the visibility of traumatic injury re- search in order to attract new researchers. Absent a significant increase in research funding, the TI Research Program can still attempt to influ- ence the number of Education Resource Centers that have a focus on safety research and can still disseminate information about the quality, impact, and scientific challenges of traumatic injury research, as well as the dynamic changes in the field that go beyond the confines of traditional safety engineering. Transfer NIOSH created a research-to-practice (r2p) initiative with six components: prioritize, partner, target, translate, disseminate, and evaluate. This initiative rec- ognizes the role of partners in this collaborative process. The TI Research Program review in Chapter 2 includes several good examples of r2p efforts, most notably the work of the AFS. However, the committee is concerned that the TI Research Program, and perhaps all of NIOSH, is not fully prepared to rigorously and expertly execute an r2p enterprise. In order to improve on this initiative, it is important that the TI Research Program allow its talented staff to focus their efforts, play on their strengths, and collaborate with others to complement their own expertise. Experts in translation should be included in project teams. As the TI Research Program develops better tracking of extramural research projects, translation ac- tivities regarding the outcomes of this research can be planned, whether through translation components included in the extramural research or by collaborations with the NIOSH transfer experts. The committee notes that it will be important for the TI Research Program to maintain a balance between basic research, applied research, and transfer activities. 8. Evaluate research-to-practice efforts. NIOSH should develop a strate- gic plan for evaluating its research-to-practice efforts and for building the capacity to carry out and evaluate these efforts. Needed disciplines include behavioral sciences; organizational behavior; intervention ef- 

16 T r a u m a t ic I n j u r y R e s e a rc h at N I OSH fectiveness research; public health education; dissemination, implemen- tation, and diffusion research; social marketing; and media advocacy. The Changing Nature of Work Recognizing the changing demographics of the U.S. workforce, NIOSH has included reducing injuries among high-risk and vulnerable populations among its strategic goals for the future. It is likewise important to address the changing nature of work itself and its interplay with the changing workforce. Work in the United States is changing in significant ways that can be expected to alter the cur- rent pattern of and risk factors for work-related traumatic injury. The industrial sectors in which U.S. workers are employed are changing. Most notably, the United States continues to shift generally from a manufacturing to a service and knowledge economy. For example, the greatest growth is projected to occur in home health care, an industry which relies heavily on immigrant and minority labor and in which the work setting is geographically dispersed. Another example is where the “craft” of residential construction is changing to a manufactured or prefabricated industry. In addition, there is likely to be a continued shift in work organization and employment practices including corporate restructuring and downsizing, shifts to leaner, more flexible production methods, and increased reliance on part-time, temporary, and contingent labor. These trends may influence work hours, job demands, benefits, and job security that may in turn adversely impact injury risks and may disproportionately affect vulnerable worker populations. Recent emphasis on the development of new sustainable technologies and green building practices offers important new opportunities for prevention through design in which the health of working people as well as the environment would be taken into account in the design stage of new products and projects. NIOSH has a cross-sector program on work organization and stress-related disorders, which was also one of the 21 priority areas for research under the ini- tial NORA. This program clearly recognizes the potential impact of the changing organization of work not only on worker health but also worker safety and has developed a research agenda to identify and address these potential risks (NIOSH, 2002). More recently NIOSH has established a program on prevention through design, which is broadly defined as addressing occupational safety and health needs in the design process to prevent or minimize work-related hazards and risks. The committee underscores the importance of TI Research Program collaboration with these other NIOSH program areas as well as the NIOSH Program on Occupational Health Disparities. 

Summary 17 9. Research prevention strategies for traumatic injuries in a changing workplace. The TI Research Program should consider research on the safety impacts of changes in the nature of work as well as intervention research targeting organization polices and practices and including prevention through design approaches. Conclusion With a focus on program improvement as outlined in this chapter, the TI Re- search Program can continue to serve as a leader in the field by identifying its niche in research, collaborating with partners, and sponsoring important high-quality research that contributes to reducing the morbidity and mortality associated with injury in the workplace. REFERENCES BLS (Bureau of Labor Statistics). 2008. Injuries, illnesses, and fatalities. http://www.bls.gov/iif/home. htm (accessed July 23, 2008). NIOSH (National Institute of Occupational Safety and Health). 2002. The Changing Organization of Work and the Safety and Health of Working People: Knowledge of Gaps and Research Directions. Washington, DC: HHS. NIOSH. 2007 (unpublished). Overview of the TI Research Program. In the evidence package provided to the Committee to Review the NIOSH TI Research Program. NIOSH. Smith, G. S., H. M. Wellman, G. S. Sorock, M. Warner, T. K. Courtney, G. S. Pransky, and L. A. Fingerhut. 2005. Injuries at work in the U.S. adult population: Contributions to the total injury burden. American Journal of Public Health 95(7):1213-1219.