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2 Assessment of Programmatic Relevance and Impact T his chapter constitutes the committeeâs response to the first part of the charge to assess the National Institute of Occupational Safety and Health (NIOSH) Traumatic Injury (TI) Research Programâs contributionâthrough occupational safety and health researchâto reductions in workplace hazardous exposures, illnesses, or injuries through â¢ An assessment of the relevance of the programâs activities to the im- provement of occupational safety and health; and â¢ An evaluation of the impact that the programâs research has had in reducing work-related hazardous exposures, illnesses, and injuries. This chapter reviews the inputs, activities, outputs, and outcomes of each of the TI Research Programâs eight goals. Much of the evidence derives from the evidence package prepared by TI Research Program staff. While the committee had informa- tion on extramural TI research grants, the information in the evidence package was presented with a focus on the work of the staff in the Division of Safety Research (DSR). Thus, the committeeâs evaluation is primarily of the TI Research Programâs intramural research and related efforts. The committee considered the TI Research Program under review to include only those activities, outputs, and outcomes included in the evidence package and evaluated the program on that basis. The committee did not attempt to independently verify the facts in the package (for example, a statement of how many brochures were mailed was believed to be ac- 43
44 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 curate), nor did the committee seek to expand the evidence by searching outside the evidence package. Although the committee was aware of some NIOSH-sponsored work that did not appear in the evidence package but that the committee would have thought part of the TI Research Program, the committee decided to evaluate only what was presented to them. The committee did use its expert judgment and knowledge of the field to evaluate claims in the evidence package about the role of NIOSH-funded work in intermediate and end outcomes. The committee did not attempt to read and evaluate the quality of each research project or each dissemina- tion product. The committeeâs evaluation was informed by the evidence package, committee expertise in the field, stakeholder input, and published material. This chapter begins with a section describing the external factors that impact the work the TI Research Program undertakes, as well as the outcomes one might reasonably expect. This is followed by a section describing issues, methods, and challenges in occupational injury surveillance, which cuts across all eight program goals. EXTERNAL FACTORS WITH BROAD IMPACT ON THE TI RESEARCH PROGRAM External factors âmay be considered as forces beyond the control of NIOSH that may affect the evolution of the programâ (see Appendix A, p. 137). They may influence NIOSH research at any phase. External factors identified by the com- mittee that broadly impact NIOSH research activities, including those of the TI Research Program, include budgetary issues (such as congressional funding and earmarks), lack of complete occupational injury surveillance data, inadequate action by regulatory agencies such as the Occupational Safety and Health Admin- istration (OSHA), the sharing of research responsibility with other agencies, and industry challenges; each of these is discussed below. External factors also impact the TI Research Programâs work in specific goal areas. Some of these are discussed in the sections that appear later in this chapter outlining each of the eight goals. Budgetary Issues NIOSH was appropriated $286 million in fiscal year (FY) 2005 to carry out its mission as the sole federal agency responsible for conducting research for the prevention of occupational injury and illness (NIOSH, 2007a, p. 17). The total TI Research Program budget for all eight research goals in FY2005 was $17.2 million (see Table 1-2), an amount the committee finds to be inadequate given the scope of the TI Research Programâs mandate. More recently, the NIOSH budget has de- creased; it was appropriated $255 million and $253 million for research in FY2006 and 2007, respectively (NIOSH, 2007a, p. 17). The FY2006 decrease reflected a new
P r o g r a m m a t ic R e l e v a n c e and I m pac t 45 Centers for Disease Control and Prevention (CDC) budget structure that draws from program allocations to support operational (overhead and indirect) costs. According to the evidence package, in 2006 Congress redirected $35 million from the NIOSH budget appropriation to CDC for business support services (NIOSH, 2007a, p. 17). Congressional funds received by the TI Research Program are sometimes ear- marked for a specific purpose, such as research that targets a specific industry or population. Such mandates have led to TI Research Program initiatives and ensured sustained research funding in several specific areas such as children in agriculture, workers in Alaska, firefighters, and workplace violence (NIOSH, 2007b, p. 47). Congress or the Department of Health and Human Services (HHS) can also assign NIOSH the task of leading or participating in research on evolving public health issues (NIOSH, 2007a, p. 17). For example, after the September 11, 2001, terrorist attacks, Congress and HHS directed NIOSH to evaluate the health of workers and volunteers at Ground Zero. These targeted areas can be productive, but the strategic decision of where to focus funds and effort is sometimes external to NIOSH and its own strategic thinking and analysis. Incomplete Occupational Injury Surveillance Data As will be discussed in greater detail in the following section, surveillance data on occupational injuries is incomplete, particularly for nonfatal injuries, due to factors such as gaps in the scope of surveillance and poor reporting of injuries in national surveys. Far more nonfatal occupational injuries than fatal occupational injuries occur each year (BLS, 2008), and risk factors for fatal and nonfatal injuries are not necessarily the same. Fatal injuries are not surrogates for nonfatal injuries. Yet the TI Research Program has had to rely primarily on fatality data to inform its research efforts. Key variables missing from data sets also interfere with the TI Research Pro- gramâs ability to do research in particular goal areas. Examples cited in the evi- dence package include lack of work relationship information in current crash data systems, which impedes the identification of risk factors for occupational crashes (NIOSH, 2007c, p. 58) and the lack of accurate data on the number of active firefighters (career and volunteer) and the number of hours of exposure, which precludes calculation of accurate firefighter fatality rates (NIOSH, 2007d, p. 154). Inadequate Regulatory Action The impact of TI Research Program activities is limited by NIOSHâs mandated inability to regulate and enforce measures that impact the occurrence of occupa-
46 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 tional injuries. According to the Occupational Safety and Health Act (OSH Act) of 1970, NIOSH is responsible for conducting research and making recommendations for occupational safety and health standards. Criteria Documents are developed to provide the basis for comprehensive occupational safety and health standards. These documents generally contain a critical review of the scientific and techni- cal information available on the prevalence of hazards, the existence of safety and health risks, and the adequacy of methods to identify and control hazards. Special Hazard Reviews (SHRs) and Occupational Hazard Assessments are written to complement NIOSH recommendations for standards. These documents assess safety and health problems and recommend appropriate methods for control and monitoring. Although OSHAâs work is informed by NIOSH research and NIOSH research can affect change in the workplace absent OSHA regulation, OSHAâin the De- partment of Labor (DOL)âis the agency ultimately responsible for the develop- ment and enforcement of workplace safety and health regulations. Regulatory inaction on the part of OSHA can delay the translation of TI Research Program findings into workplace policies. Additionally, depending on the research area, inaction or underachieved expectations on the part of regulatory agencies other than OSHA (e.g., the Department of Transportation or the U.S. Department of Agriculture [USDA] or other agencies) can also stall translation of TI Research Program findings. In the absence of regulations, employers may be less likely to adopt safety measures. Exemptions from federal occupational safety and health regulationsâsuch as the exemption from the 1970 OSH Act of employers of public-sector workers, the congressional exemption for farms employing fewer than 11 people, and the fam- ily farm exemption in federal child labor lawsâare also barriers to application of some of NIOSHâs research findings. Sharing Research Responsibility with Other Agencies Garnering support for research where there is a shared responsibility can be complicated when the occupational component represents a relatively small pro- portion of the overall societal problem. For example, this has been true for NIOSH in the area of injuries due to motor vehicle incidents; although NIOSH focuses solely on occupation-related crashes, it still shares research responsibility with the âDuring the time period of the committeeâs evaluation, NIOSH has issued four Criteria Documents and one SHR. The last Criteria Document was issued in 2006; the previous was issued in 1998. Only the 1997 SHR, Child Labor Research Needs, addressed a TI concern. âOSHA and the Mine Safety and Health Administration have delegated approval of respirators to NIOSH.
P r o g r a m m a t ic R e l e v a n c e and I m pac t 47 National Highway Traffic Safety Administration (NHTSA). Occupation-related crashes represent only about 3 percent of the total number of motor vehicle crashes (NIOSH, 2007c, p. 58), a fact that has made it difficult for the TI Research Program to synergistically and strategically engage the broader traffic safety community and also results in the exclusion of some occupational risk factors from national policy (e.g., exclusion of ambulances from crashworthiness consideration). To some extent the same has also been true for research on workplace violence, because violence that occurs in the workplace is a comparatively small part of the overall problem of violence. Sharing research responsibility with other agencies can also make causal at- tribution of end outcomes to the TI Research Programâs research findings more complicated (e.g., decreases in occupationally related motor vehicle deaths and workplace homicides can be reflections of an overall change in motor vehicle deaths and homicides rather than occupational initiatives). Industry Challenges Some challenges to conducting research are related to the nature of the indus- tries targeted by the TI Research Programâfor example, the mobile nature of the agriculture and construction industries and the small-business composition of the retail industry. It is difficult to enlist employer participation in studies to prevent rare events. There are also barriers to corporate investment in injury prevention technologies that are related to there being no accepted way of predicting how improvements in workplace safety will reduce the risk of worker injury. ORGANIZATIONAL DESIGN Strategically and organizationally, the TI Research Program supports a larger NIOSH mission. In terms of organizational design, the TI Research Program has been an instrumental part of the crosscutting NIOSH Program Portfolio Matrix Management Initiative (Table 1-1). NIOSHâs formal organizational structure de- picts DSR as part of a product/service organizational structure with geographic distribution. Its Matrix Management Initiative has recently been reorganized to be industrial-sector programs Ã crosscutting programs, of which the TI Research Program is a component. The traditional benefits of matrix management include the flexibility derived from resourcing from both axes of the matrix. The TI Research Program goals â As described in Chapter 1, the coordinated emphasis areas have been moved into the cross- cutting programs.
48 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 represent a mix of risk factors in different occupations, various work environments, and different vulnerable populations. Since goals are in crosscutting categories and NIOSH is organized in a matrix, the assumption is that the structure (matrix) will support the strategy of crosscutting research, but previous users of matrix organi- zational structures caution that the structure can also be a source of overlap and inefficient use of resources. As an example, âfall from heights,â a major source of occupational injury and fatality, is a major problem across sectors (construction falls from rooftops, surface mining falls from heavy equipment, falls from towers in telecommunications, etc.). Falls may be experienced disproportionately by some worker groups (e.g., Latinos) as well as in certain firms (e.g., small). Given the relatively modest budget for occupational health and safety research in general, the organizational structure should support information sharing and efficient use of resources in such cases, rather than having multiple, parallel efforts to address a common issue. Of particular concern is whether the crosscutting programs and the sector programs are maximizing the efficient use of resources and information. Matrix management is an attempt to provide flexibility in terms of personnel assignment and reassignment and in a sense, an attempt to allow the benefits of the two axes while promoting synergistic additional benefits. In terms of injury prevention, there is great potential. To illustrate the potential of crosscutting and true matrices, consider Haddonâs matrix (Haddon, 1968, 1972). Combining his medical and engineering expertise, Haddon provided a âmatrixâ for analyzing injury based on the person injured, the cause of the injury, and the environment and for identifying temporal factors across the pre-event, event, and post-event life cycle. To further investigate the root cause of falls from heights discussed earlier, kinetic energy is closer to the root cause and, in fact, is the most common agent that causes occupationalÂ injury (e.g., tissue tearing, crushing with bleeding, organ failure and death from car crashes, falls, gunshot wounds). While prevention, modification, or attenuation of the release of this energy is common across all of the sectors that NIOSH has created, the TI Research Program (as well as many or most others) may be stuck between sectors, simply because of the way NIOSH is organized. One potential solutionâif reorganization is not desired or practicalâis to use something like Haddonâs matrix as what is called in the organizational field an âintegrating mechanismâ that facilitates the organization and integration of common information. In summary, there are common pitfalls with matrix management that should be noted as the TI Research Program and NIOSH continue to evolve. Internally, there can be confusion over lines of authority for personnel attached to multiple programs or units within the organization. Although this classic challenge was not observed in the committeeâs review, the related issue of project âownershipâ and associated information sharing was observed. That is, it was sometimes difficult to fully un-
P r o g r a m m a t ic R e l e v a n c e and I m pac t 49 derstand which projects fell under the purview of the TI Research Program, because of its positioning within a matrix structure. The committee is an external body to which NIOSH needed to communicate its framework structure and processes, and committee members were occasionally confused about the TI Research Programâs responsibilities within that framework. As NIOSH continues to work externally, for example, in sharing responsibility with other agencies, it will have to commu- nicate effectively how it is structured organizationally (i.e., product/service), how it is managed (matrix), and how it operates (logic model), and more importantly, it should effectively share and manage its portfolio of injury prevention knowledge in a resource efficient manner (e.g., effective integrating mechanisms). SURVEILLANCE Surveillance of traumatic injuries provides the empirical basis for setting research priorities and for evaluating the impact of research, knowledge transfer, and intervention activities. Although substantial strides have been made over the past 20 years in the development of a national surveillance system for fatal occu- pational injuries, there is widespread evidence of substantial disparities between the number of nonfatal occupational injuries that are reported and the actual number that occur. A series of studies beginning in the 1980s demonstrated that both nonfatal and fatal injuries are underreported (Azaroff et al., 2002; Stout and Bell, 1991). Based on these studiesâmany of which were performed or supported by NIOSHâthe TI Research Program developed the NTOF (National Traumatic Occupational Fatality) Surveillance System. This system provided much improved reporting of injuries resulting in death and contributed to the creation of the Census of Fatal Occupational Injuries (CFOI) in 1992. Improved surveillance of fatal occupational injuries is an impressive achievement of the TI Research Program and is currently an important input into the TI Research Programâs planning process. The TI Research Program also expanded fatality surveillance by establishing the Fatal Assessment Control and Evaluation (FACE) Program. This program, con- ducted in collaboration with state partners, provides in-depth information about âThe NIOSH FACE Program concentrates on investigations of fatal occupational injuries. It has two componentsâan in-house program that began in 1982 in which participating states voluntarily notify NIOSH of traumatic occupational fatalities resulting from targeted causes of death (currently, deaths associated with machinery, deaths of youths under 18 years of age, and street/highway construction work zone fatalities) and a state-based program that began in 1989 in which nine states with coopera- tive agreements with NIOSH conduct surveillance, targeted investigations, and prevention activities using the FACE model (NIOSH, 2008). The number of state-based FACE programs has declined in recent years due to lack of funding despite a growing interest and expertise on the part of the states.
50 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 targeted types of deaths. This informationâcollected through onsite, research- oriented field investigations of fatal incidentsâis used to develop recommenda- tions to prevent future deaths. These recommendations are in turn disseminated widely to industry and labor professionals, manufacturers, policy makers, and health and safety professionals. Although substantial strides have been made in the surveillance of fatal oc- cupational injuries, many types of traumatic workplace injury rarely result in death, and fatal injuries are not good surrogates for nonfatal injuries. Planning and evaluation also depend on accurate surveillance of nonfatal injuries. It is widely recognized that the current major source of national surveillance data on nonfatal occupational injuriesâthe Bureau of Labor Statistics (BLS) Annual Survey of Injuries and Illnessesâis very incomplete. National estimates of injuries derived from this survey exclude approximately 22 percent of the U.S. workforce, includ- ing workers in the public sector and the self-employed (Leigh et al., 2004). There is also mounting evidence of injury underreporting on the OSHA-required injury logs maintained by employers on which the survey is based (Conway and Svenson, 1998; Rosenman et al., 2006). Moreover, completeness of reporting likely varies by type of injury, employer characteristics, and worker characteristics, although due to the nature of the problem the extent of variability is unknown. Gaps in surveillance and incomplete reporting result in substantial underesti- mates of the national burden of occupational injuries. As a consequence, decisions based on these data may allocate fewer resources to research and interventions designed to reduce workplace hazards. Secular changes in reporting over time can (if reporting improves) suggest that successful programs have failed or (if reporting declines) suggest that ineffective programs have succeeded. In addition, differen- tial reporting by condition, subpopulation, or employer type can lead to focusing prevention efforts in the wrong areas. Injuries for which we have particularly poor measures of incidence may receive inadequate public health attention. The TI Research Program has carried out substantial surveillance activities and research in order to provide more reliable surveillance data, including data on nonfatal injuries. Perhaps the most innovative of these efforts has focused on ag- riculture and young workers. The Child Agricultural Injury Program, for example, has developed several new surveillance activities designed to provide an ongoing picture of the incidence of injuries among both adults and youths. For adult farm workers, Occupational Injury Surveillance of Production and Agriculture (OISPA) surveys farm operators to estimate the number and incidence of occupational inju- ries to adults working on farms. In addition, NIOSH has developed a farm worker injury module to supplement data already collected from workers by the DOL in the National Agricultural Workers Survey (NAWS). This survey includes both adult and young workers. Using ongoing survey relationships of the National Agricultural
P r o g r a m m a t ic R e l e v a n c e and I m pac t 51 Statistics Service (NASS), NIOSH has collected information from farm operators about agricultural injuries to youth in 1998, 2001, and 2004 (the Childhood Agri- cultural Injury Surveys [CAIS]). A parallel survey of minority farms, the Minority Farm Operator Childhood Agricultural Injury Surveys (M-CAIS), was conducted in 2000 and 2003. These surveys include a project that ascertained the number of agricultural injuries incurred by ninth to twelfth graders in Minnesota as reported by emergency departments. Since the early 1990s, NIOSH has had an interagency agreement with the Consumer Product Safety Commission to collect data on nonfatal occupational injuries through the National Surveillance of Nonfatal Occupational Injuries Using the National Electronic Injury Surveillance System (NEISS). NEISS collects data on injuries resulting in emergency department visits from a sample of U.S. hospitals. Not all injuries are seen in emergency departments, but the agreement has allowed NIOSH to collect data on nonfatal injuries for all industries and occupations and has allowed for better understanding of risk factors, particularly for those injuries that are more likely to require emergency department visits. Through the agree- ment, NIOSH has also been able to conduct follow-up surveys of injured workers to collect more detailed information on their injuries. To describe risks to working youth, NIOSH has used NEISS and developed new surveillance sources both by building on existing surveys conducted by other a Â gencies and by funding new surveillance activities. These include new state- based surveillance activities in Wisconsin and Massachusetts focused on working youth. Despite these activities, there remains a paucity of high-quality national data on nonfatal injuries. This may be one reason that the TI Research Program frequently seems to focus on fatality data in setting program priorities. Although fatal injuries should carry substantial weight, too much emphasis on fatalities can lead to an underinvestment in research and transfer activities relevant to injury types that are very rarely fatal yet impose significant human and economic costs. Notably, occupational injury surveillance is dependent upon having valid information about the number of injuries that occur. It also requires information about populations at risk (denominator data) necessary to generate injury rates that allow for identification of disproportionate risks among segments of the population and subsequent priority setting. Better information on employment and hours at work (as well as injuries) is also needed, especially for the vulner- able populations such as youth and immigrant and minority workers whose work experience may not be well captured in traditional sources of employment data. Optimally, information on worker exposure to hazards would be available to allow for exposure-based estimates of risk. NIOSH, in concert with other agencies, can work to develop better systems for capture of denominator data.
52 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 In summary, NIOSH has engaged in a range of activities, both intramural and extraÂmural, that have made strong contributions to improving surveillance. Still, these projects do not appear to be part of a coordinated interagency strategy to improve national surveillance of traumatic nonfatal occupational injuries. For example, there is little research funded to identify the strengths and weaknesses of current national systems or to find ways of combining data to generate better estimates of injury incidence. NIOSH has used population-based surveillance data, but more work could be performed to identify the strengths and weaknesses of new survey-based systems or to attempt to compare or combine data. In its future TI Research Program activities, NIOSH would benefit from an overall strategy of sur- veillance research and implementation designed to lead to a better national nonfatal injury surveillance program. This might be considered as a separate goal. Goal 1: reduce injuries and fatalities due to Motor Vehicles NIOSH and the TI Research Programâs involvement in motor vehicle injury research began in the late 1990s in response to data demonstrating a lack of progress in reducing work-related crashes and fatalities. At this time, TI Research Program staff also recognized the problem of poor data capture tying crash incidents to oc- cupational injuries in crash data systems. No one had yet taken the lead in making improvements in this area (NIOSH, 2007c, p. 53). The committee supports NIOSHâs decision to become a key player in motor vehicle injury research. There is a niche for NIOSH to evaluate aspects of motor ve- hicle injuries and workplace intervention strategies that are not already researched by other agencies. NIOSH developed two subgoals for research aimed at reducing injuries and fatalities due to motor vehicles: 1.1. Reduce occupational injuries and fatalities due to highway motor vehicle crashes 1.2. Reduce occupational injuries and fatalities due to motor vehicle incidents in highway and street construction work zones Planning and Production Inputs Planning inputs were comprehensive and supported the need for research in both subgoal areas. Inputs were both qualitative and quantitative. â Subgoal 1.1 specifically targeted (1) professional truck drivers and (2) workers who drive or ride in motor vehicles during work-related travel but who are not professional drivers (NIOSH, 2007c, p. 54).
P r o g r a m m a t ic R e l e v a n c e and I m pac t 53 Subgoal 1.1 inputs included fatal and nonfatal crash injury data from the BLS, which allowed identification of important crash risk factors for truck drivers. A qualitative source of input was feedback from stakeholders at conferences and meetings, which revealed agreement on a need for additional surveillance and risk factor research for truck drivers. The TI Research Programâs research on workers who drive or ride in motor vehicles during work-related travel, but who are not professional drivers, was initiated to address a research and regulatory gap (NIOSH, 2007c, pp. 54-55). An important input into the TI Research Programâs work on subgoal 1.2 was a review of BLS data, which showed that most fatalities occurring at road con- struction sites between 1995 and 2002 were reported to be transportation-related incidents (NIOSH, 2007c, p. 62). There had also been concern among stakeholders that increases in worker injuries would occur in coming years due to increases in road construction and structural changes in the industry, making this a potentially emerging issue (NIOSH, 2007c, p. 62). Combined intramuralâextramural funding for motor vehicle research for the period FY1997-2005 totaled $12,657,927. Only the back injury program had lower total funding for this period. With the exception of a small funding decline in FY2003, intramural funding for motor vehicle research increased each year from FY1997 to FY2005, reflecting the growth of this program over time. However, the proportion going to extramural research began to decline in FY2003, and in FY2005, it accounted for less than 1 percent of the total funding for motor vehicle research (see Table 1-2). Full-time equivalents (FTEs) increased from a low of 4.3 in FY1998 to 14.8 in FY2005. Activities Activities for subgoal 1.1 included surveillance research as well as research to identify crash risk factors and interventions. Perhaps owing to the fact that NIOSH and the TI Research Program are relatively new to motor vehicle safety research, activities for subgoal 1.1 were rather limited given the broad scope of the goal. The committee agrees with the TI Research Program that it is continu- ing to develop a niche within transportation safety research. Appropriately, the TI Research Program has been working with partners such as the American Society of Safety Engineers and the Network of Employers for Traffic Safety to learn how it can best serve employers and employee drivers through research and outreach (NIOSH, 2007c, p. 55). Having focused motor vehicle safety research goals (rather than the broader goal of reducing injuries and fatalities due to highway motor ve- hicle crashes) will be important for informing the TI Research Programâs activities going into the future.
54 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 For subgoal 1.2, which the committee finds to be an excellent niche for the TI Research Program, highway and construction work zones were added as a target for FACE investigations by the program in 1999. TI Research Program staff has since completed 12 FACE investigations involving transportation-related incidents in high- way and street construction zones (NIOSH, 2007c, p. 63), and the state-based FACE program has conducted investigations of more than 50 highway work zone deaths (NIOSH, 2008). FACE investigations have been for worker fatalities from motor ve- hicles used for construction, as well as worker fatalities from passing motor vehicle traffic. These investigations represent a significant contribution to the knowledge of factors potentially contributing to work zone deaths. From 2000 to 2002, the TI Research Programâs work for subgoal 1.2 was focused largely on intervention research that tested the effectiveness and reliability of prox- imity warning systems (PWS) in alerting equipment operators and workers when workers enter blind areas around road construction site equipment. The focus on this intervention is appropriate given the data demonstrating that most fatalities occurring at road construction sites between 1995 and 2002 involved workers be- ing struck by a vehicle or mobile equipment (NIOSH, 2007c, p. 62). In 2002, the TI Research Program began testing some PWS devices, as well as an internal traffic control plan (ITCP) on active construction road sites. Neither the PWS devices nor the ITCP have yet been proven effective (NIOSH, 2007c, p. 63), but additional research is planned to evaluate their effectiveness on highway construction sites (NIOSH, 2007c, p. 65). The committee supports the TI Research Programâs decision to continue research in this area for eventual work site implementation. Some diffusion and dissemination research has been performed for subgoal 1.2 in the form of evaluations of effectiveness of safety training programs for Spanish- speaking road construction workers. This is an important area for research because of the large and growing number of Spanish-speaking construction workers. The NIOSH Education and Information Division is heading this effort (NIOSH, 2007c, p. 63). Transfer Activities The TI Research Program has engaged in proactive transfer activities for both motor vehicles subgoals. A planned transfer effort is demonstrated for subgoal 1.1, where TI Research Program staff developed dissemination strategies for NIOSH publications on mo- tor vehicle safety. More than 120,000 of these publications have been distributed to targeted distribution lists and at conferences. The TI Research Program also âITCPsrepresent an administrative approach designed to assist in controlling construction vehicle and worker movements inside the work zone (NIOSH, 2007c, p. 63).
P r o g r a m m a t ic R e l e v a n c e and I m pac t 55 prepared and disseminated a Hazard Review discussing identification of worker groups at high risk of crashes, among other injuries. Press releases were used to increase the visibility of some NIOSH and NIOSH-funded projects related to mo- tor vehicle safety (NIOSH, 2007c, pp. 56-57). For subgoal 1.2, approximately 21,000 copies of the NIOSH publication âBuild- ing Safer Highway Work Zones: Measures to Prevent Worker Injuries from Vehicles and Equipmentâ were distributed through targeted mailings and handouts at conferences and exhibitions. This document was authored by TI Research Program staff and outlines measures for reducing injuries in highway work zones (NIOSH, 2007c, p. 63). Other transfer activities involving dissemination have been more passive. The NIOSH publication âBuilding Safer Highway Work Zones: Measures to Prevent Worker Injuries from Vehicles and Equipmentâ and the FACE investigation reports are available for download from the NIOSH Web site. Technical assistance in the form of diagrams of blind areas for work zone equipment is distributed externally upon request (NIOSH, 2007c, pp. 63-64). TI Research Program staff involvement on the American National Standards Institute (ANSI) Z15 committee is an important collaborative transfer activity. The ANSI Z15 committee developed ANSI standard Z15.1-2006, which outlines minimum standards for workplace traffic safety training programs. The standard impacts employers whose employees drive for work. TI Research Program staff contributed to all parts of the standard and led the development of the portion of the standard on crash data collection and incident analysis (NIOSH, 2007c, p. 55). Outputs The TI Research Program for motor vehicles has produced a number of out- puts, including FACE investigations, peer-reviewed journal articles, and NIOSH publications, and has sponsored workshops and conferences. The TI Research Program does not appear to have generated new knowledge per se related to sub- goal 1.1. Instead, outputs have focused on describing risks and new applications of previously used research methods. There do not appear to be widely cited peer- reviewed publications of breakthrough results. Outputs for subgoal 1.2âin par- ticular the TI Research Program-authored NIOSH report âBuilding Safer Highway âPratt,S. G., D. E. Fosbroke, and S. M. Marsh. 2001. Building safer highway work zones: Measures to prevent worker injuries from vehicles and equipment. HHS (NIOSH) Publication No. 2001-128. âSee footnote 7 for reference.
56 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 Work Zones: Measures to Prevent Worker Injuries from Vehicles and Equipmentâ and the 13 highway work zone FACE investigationsâare more innovative. Outcomes TI Research Program staffâs contribution to the development of the ANSI Z15.1 standard is an important intermediate outcome. The standard will likely lead to workplace change, especially for small businesses, through the guidance it provides on how to protect the safety of workers who drive as part of their work. Approval of this standard is a noteworthy accomplishment because the Federal Motor Carrier Safety Regulations apply only to commercial drivers, leaving many small- and medium- sized carriers without guidance for establishing or carrying out a motor vehicle safety program. Although TI Research Program staff participation in standards setting and other consensus activities is necessary and is recognized as such by the committee, it is difficult to know what proportion of the success of the ANSI standard was the result of the TI Research Program staffâs participation in its development. Another very important intermediate outcome was the incorporation of a NIOSH recommendation related to Hazardous Occupations Order (HO) No. 2 (motor vehicle occupations) into a final rule published by the DOL in 2004. NIOSHâs recommendation was that the HO be changed to comply with 1998 con- gressional amendments to the Fair Labor Standards Act (FLSA) (NIOSH, 2007c, p. 57), which outlined new rules for teenagers who drive for work (the Teen Drive for Employment Act [P.L. 105-334]). The DOL adopted the recommendation and published a final rule10 on the HO, which prohibits all workplace driving on public roadways by 16-year-olds and places restrictions on workplace driving by 17-year-olds. There are other indicators of stakeholder use of the TI Research Programâs work on work zone safety. The NIOSH publication âBuilding Safer Highways and Work Zones: Measures to Prevent Worker Injuries from Vehicles and Equipment,â11 for example, has been used by stakeholders for a variety of purposes and has resulted in workplace changes to safety training. Key measures from this document have been incorporated into course materials for an OSHA training course provided to member construction companies for the National Safety Council and the Ameri- âSee footnote 7 for reference 10âRegulations implementing the act permit the Secretary of Labor to prohibit the employment of youth in occupations declared âparticularly hazardous for the employment of children . . . or detri- mental to their health or well-beingâ (29 USC 201 Sec. 3(1)). These prohibited activities are referred to as Hazardous Occupations Orders (HOs). The minimum age, by statute, for HOs in nonagricul- tural occupations is 18; the minimum age in agricultural occupations is 16. 11âSee footnote 7 for reference.
P r o g r a m m a t ic R e l e v a n c e and I m pac t 57 can Road and Transportation Builders Association. This document has been used by a variety of other organizations (universities, an insurance company, and the Federal Emergency Management Agency, among others) as well for purposes such as safety training and strategic planning, informing best-practice guidelines, and the development of risk management recommendations (NIOSH, 2007c, p. 64). Stakeholders have also expressed interest in the diagrams of blind areas around work zone equipment. These reports have been requested and used by one stateâs health department for the development of recommendations for internal traffic control, by PWS device manufacturers for product development and marketing, and by construction companies for safety training (NIOSH, 2007c, p. 65). Discussion The TI Research Program is to be commended for recognizing a decade ago that motor vehicles are a major contributor to occupational injury and death and it has an important role in motor vehicle injury research. As stated previously, NIOSH and the TI Research Program are continuing to find their niche within transportation safety research and are collaborating with partners to identify how research can best meet employer and employee work- related motor vehicle safety concerns. It is perhaps for this reason that activities for subgoal 1.1 were rather limited for the evaluation period. The committee found research activities for subgoal 1.2 on work zone safety to be highly relevant and a good use of the TI Research Programâs limited resources to make a contribution to a focused area not researched by other agencies. A discussion of possible future motor vehicle injury research areas for the TI Research Program is included in Chapter 3 of this report. Both subgoals showed a broad array of transfer activities. The technical as- sistance provided by TI Research Program staff to the ANSI standards committee is particularly admirable. Although activities for subgoal 1.1 were not particularly innovative, many important outputs resulted from this work. The approval of the ANSI Z15.1 standard and the incorporation of the NIOSH recommendation to revise the FLSA section on child labor are strong intermediate outcomes impacting safety training and regulations for workplaces. Goal 2: Reduce injuries and fatalities due to Falls from Elevations NIOSH developed three subgoals for its research aimed at reducing falls from elevations:
58 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 2.1. Reduce worker falls from roofs 2.2. Improve fall-arrest harnesses 2.3. Reduce worker falls from telecommunications towers Planning and Production Inputs Quantitative inputs to the TI Research Programâs work on falls from eleva- tions were BLS data on the number of fatal and nonfatal occupational injuries resulting from falls from elevations as well as information on societal costs. The construction industry was identified as having the highest frequency of falls from elevationsâmost often from roofs, ladders, and scaffolds. OSHA regulations re- quire the use of harnesses, guardrails, or safety nets for tasks that are performed above 6-feet height (NIOSH, 2007e, p. 69). A comprehensive literature review identified factors and information gaps related to subgoal 2.1. A lack of current anthropometric data relevant to harness design was noted in the establishment of subgoal 2.2 (NIOSH, 2007e, p. 75). Subgoal 2.3 is shaped by statistics showing that the fatality rate from falls in the telecommunications industry is as much as a hundredfold higher than the average fatality rate across all industries. A doubling of fatalities between 2005 and 2006 is further justification for attention to this area (NIOSH, 2007e, p. 78). The total intramural and extramural combined funding for this project between FY 1997 and FY 2005 was $14,449,742 ($12,148,782 intramural and $2,300,960 ex- tramural). The funding amount seems to be fairly consistent over all 9 years, rang- ing from $1,136,996 in FY 1999 to $1,853,368 in FY 2003. One noteworthy change is that in FY 2005, the extramural funding was reduced to only $250, which may indicate that NIOSH will phase out extramural funding in this area altogether. FTEs ranged from a low of 8.0 in FY 1998 to a high of 15.4 in FY 2000 (Table 1-2). Overall, the committee found the subgoals to be appropriate for the overarch- ing challenge of reducing falls from elevations. The committee was surprised, however, to see no formal recognition by the TI Research Program of slips, trips, and falls from the same elevation. Although work-related slips, trips, and falls from the same elevation do not result in as many fatalities as falls from heights, they do occur more often and are a significant source of morbidity and costs. Activities The TI Research Program has taken a strong engineering approach in this area. For subgoal 2.1, it developed new technologies and used its virtual reality lab to better understand balance and sensory cues. Specifically, the TI Research Program developed an adjustable guardrail, validated virtual reality technology
P r o g r a m m a t ic R e l e v a n c e and I m pac t 59 for fall prevention research, identified the effects of visual cues on balance control, developed improved footwear designs, established sensory-enhancing technology to improve worker balance, and developed safer scissor lifts and work practices. The TI Research Program also used virtual reality technologies and sensory enhancing technologies and developed safer scissor lifts (NIOSH, 2007e, pp. 70-71). To improve fall-arrest harnesses, the TI Research Program used advanced scanning technology in a pilot study to perform full-body scans of actual workers in actual work positions (standing and suspended). It then demonstrated that the current criteria for fit were inappropriate for two harnesses. In so doing, the TI Research Program demonstrated the need for updated harnesses. Working with harness manufacturers, it updated mathematical parameters that were applied to a much larger anthropometry database in order to enable determinations of necessary adjustments to harness components. The TI Research Program also determined that another of its inventionsâa harness accessory that would right a fallen worker to a sitting positionâlengthened the time a suspended fallen worker could endure without physiologic stress (NIOSH, 2007e, pp. 75-76). Activities for subgoal 2.3 were FACE investigations of 12 telecommunications tower-related fall fatalities that occurred from 1992 to 2001. The leading causal factors for these falls were determined to be failure to use or improper use of per- sonal protective equipment; improper, inadequate, and improper maintenance of hoisting equipment; and inadequate employer safety programs and training. The TI Research Program also reviewed BLS and OSHA data to identify and charac- terize fatal falls that occurred from 1992 to 2005 among workers constructing or maintaining telecommunication towers (NIOSH, 2007e, p. 78). This work led to transfer activities and outputs, which are described below. Transfer Activities The TI Research Program has engaged in significant transfer activities for its research on falls. Specifically, the program has been successful at generating the interest of potential manufacturers in several technologies. A patent was filed for the guardrail assembly and the TI Research Program held a workshop to engender interest in the use of the new system (NIOSH, 2007e, p. 70). Two companies have expressed interest in the product and are conducting product development and cost analyses. The virtual reality technology developed by the TI Research Program is of interest to other countries, which would greatly extend this work. The TI Research Program has signed a letter of agreement with a scissor lift manufacturer to jointly develop aerial lift designs. The partner is testing TI Research Program-developed software to determine its applicability to new lift design (NIOSH, 2007e, p. 77).
60 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 With regard to subgoal 2.2, the TI Research Program has initiated efforts with two major harness manufacturers that account for more than half of the national market share to incorporate the anthropometric findings into more appropriate harnesses. For subgoal 2.3, the TI Research Program has led the transfer of findings to workers and companies through the dissemination of FACE reports through National Association of Tower Erectors (NATE) conferences and OSHA training classes, its participation in OSHA Telecommunications Task Force efforts, and the dissemination (in English and Spanish) of the NIOSH Alert âPreventing Injuries and Deaths from Falls During Construction and Maintenance of Telecommunica- tion Towersâ12 (NIOSH, 2007e, p. 78). One concern, however, is that many construction companies are small- to medium-sized enterprises, and the workforce includes a great many non-English speakers. The evidence package does not demonstrate serious attention to the spe- cial problems of these stakeholders nor does it outline special efforts to disseminate the information particularly to small businesses. Outputs The major outputs of this program include four journal articles, nine confer- ence presentations, one NIOSH publication, 11 FACE reports, and one provisional patent application.13 Outcomes The evidence package documents intermediate outcomes for subgoal 2.3 only, although the many transfer activities documented in a previous section suggest likely intermediate outcomes in the near future. The OSHA Telecommunications Task Force issued a compliance directive,14 which contains procedures for the inspection of tower construction sites and procedures for tower construction. OSHA now requires 100 percent fall protection, meaning protection for the entire time a worker is off the ground. A revision of that directive removed an important restriction, namely that an erector can now ride a hoist no matter the height off 12âNIOSH. 2001. NIOSH Alert: Preventing injuries and deaths from falls during construction and maintenance of telecommunication towers. HHS (NIOSH) Publication No. 2001-156. 13âThe provisional patent application was filed in July 2006 for a harness accessory, which automati- cally supports a wearer in a sitting position with the knees elevated at a position at or above the hips after a fall (CDC Ref. No. I-002-06) (NIOSH, 2007f, p. A-10). 14âCPL 02-01-029-CPL 2-1.29âInterim Inspection Procedures During Telecommunication Tower Construction Activities.
P r o g r a m m a t ic R e l e v a n c e and I m pac t 61 the ground (a previous directive limited this to 200 feet above the ground). These directives were based on TI Research Program findings (NIOSH, 2007e, p. 79). NIOSH analysesâincluding FACE investigationsâwere used as the basis for the North Carolina Telecommunications Tower Standard, which outlines proper safety procedures to be used during tower construction and maintenance. Other uses of TI Research Program investigations in telecommunications tower-related concerns led to an OSHA safety checklist and a 3-day âtrain-the-trainerâ program for OSHA compliance officers, contractors, component manufacturers, and tower owners and erectors. NATE used the TI Research Program findings as part of the evidence base for a comprehensive safety and health manual as well as a recom- mended best-practices site safety manual. Other intermediate outcomes include providing the Federal Aviation Administration (FAA) with information it found useful when retrofitting a damaged antenna in the Bahamas and providing the United Kingdom with safety information pertaining to working safely at heights (NIOSH, 2007e, p. 79). The TI Research Program does not report effects on end outcomes other than to note that there is no evidence that the number of tower erector fatalities has decreased, likely because there is not enough information on the number of erec- tors being built or repaired to allow for calculation of the rate of fatalities from falls in the industry. The number of telecommunications towers is likely increasing, so it is possible that with better surveillance a decrease in the rate of fatal falls could be documented. Discussion The TI Research Programâs research on falls from elevations addresses an important source of workplace fatalities, especially in the construction industry. The projects include research on different approaches to reducing the risk of falls from roofs, the development of better fall-arrest harnesses, and an effort to reduce the risk of falls in high-risk industries (telecommunications tower maintenance and construction). The projects appear to have the promise of developing bet- ter prevention methods and are focused on important prevention issues relevant to the problems being addressed. The research results have been published and disseminated, and the research group has made productive efforts to work with manufacturers, industry and labor representatives, and other stakeholders in order to develop, carry out, and disseminate these results. The committee identified some weaknesses with this part of the TI Research Program. There appeared to be no research focusing on falls from the same level, a major source of workplace injuries, and the coordination of this research with NIOSHâs Construction Safety Research Program is not clearly evident, although
62 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 similar research is being conducted in that program. Overall, the program might benefit from better coordination with other programsâincluding construction, mining, and agricultureâand from expansion to include traumatic injuries due to falls from the same elevation. GOAL 3: REDUCE INJURIES AND FATALITIES DUE TO WORKPLACE VIOLENCE There are no subgoals for the TI Research Programâs goal on workplace vio- lence. Historically, the programâs intramural work has focused on Type 1 violence,15 or criminal intent, where the perpetrator of the violence enters the business with the intent to commit a crime and has no relationship to a business or its employees. The extramural program targets all types of workplace violence and is intended to complement the intramural program (NIOSH, 2007g, p. 84). Planning and Production Inputs Quantitative inputs into the TI Research Programâs work on workplace vio- lence were NTOF surveillance data on numbers of fatal and nonfatal occupational injuries resulting from workplace violence, as well as the types of job settings in which workplace violence occurs. The TI Research Program also noted the societal cost of workplace homicide, which was estimated to be approximately $6.5 billion for 1992 to 2001. The TI Research Program has also received input on workplace violence through national conferences, workshops, and stakeholder meetings. In response to receipt of a $2 million appropriation from Congress in 2002 in support of research on workplace violence research, NIOSH created the Federal Interagency Task Force on Workplace Violence Research and Prevention (NIOSH, 2007g, p. 87). 15â Workplace violence has been categorized into four types for public health attention (Merchant and Lundell, 2001): Type I is a criminal intent in which the perpetrator has no legitimate relationship to the business or its employees, and is usually committing a crime in conjunction with the violence. These crimes include robbery, shoplifting, and loitering. A large portion of Type I violence occurs in the late-night retail industry. Type II is customer or client violence in which a perpetrator has a legitimate relationship with the business and becomes violent while being served by the business. This category includes customers, clients, patients, students, inmates, and other groups for which a busi- ness provides services. A large portion of Type II violence occurs in the healthcare industry, in settings such as nursing homes or psychiatric facilities where the victims are often patient caregivers. Police officers, prison staff, airline employees and teachers provide other examples of workers exposed to this violence. Type III is worker-on-worker violence in which the perpetrator is an employee or past employee of the business who attacks another employee. Type IV is personal relationship violence in which the perpetrator does not have a relationship with the business but with the victim.
P r o g r a m m a t ic R e l e v a n c e and I m pac t 63 The task force is comprised of representatives from 20 federal agencies. NIOSH has coordinated and hosted four task force meetings since 2002 at which attend- ees share information and identify opportunities for collaboration. This has been an important source of input into the TI Research Programâs workplace violence research (NIOSH, 2007f, p. A-14). NIOSH also held a series of stakeholder meet- ings in 2003 to gather input on workplace violence in the healthcare, retail, and security and law enforcement industries and on domestic violence in the workplace (NIOSH, 2007f, p. A-15âA-16). The total intramural and extramural combined funding for research on work- place violence for the period FY1997-2005 was $20,254,590. Only the working youth program had higher overall funding for this period. With the exception of FY1997, funding was higher each year for extramural than for intramural research on workplace violence research (see Table 1-2). In FY2002, the TI Research Pro- gram received a $2 million appropriation from Congress to support research on workplace violence. The appropriation resulted in a near doubling of total fund- ing. Approximately 25 percent of appropriated funds have supported intramural research and 75 percent have supported extramural research (NIOSH, 2007g, p. 83). FTEs ranged from a low of 4.5 in FY1998 to a high of 9.5 in FY2004. Activities TI Research Program activities for workplace violence included surveillance, risk factor research, intervention effectiveness research, and transfer. The commit- tee found these activities to be relevant to the challenge of reducing injuries and fatalities due to workplace violence. Workplace violence research has addressed high-priority needs. For the pe- riod 1990-1998, the TI Research Program focused intramural research on Type 1 violenceâcriminal intentâthe most prevalent type of fatal workplace violence. This research reviewed robbery and robbery-related risk factors for late-night retail workers who are at especially high risk for workplace violence. The findings from this research were also helpful in supporting elements of Crime Prevention Through Environmental Design programs and creating recommendations for the prevention of workplace violence in NIOSH documents and OSHA guidelines. A very important collaborative intramural activity was the TI Research Pro- gramâs work to address the high-priority issue of a gap in data on nonfatal injuries from workplace violence. Working with the DOL, the TI Research Program funded and inserted modules of questions to capture data on nonfatal injuries into three national surveys between 2002 and 2006 (NIOSH, 2007g, p. 85). The committee sees this as a significant contribution to the knowledge base on workplace violence and supports plans to complete analyses and publications of findings from these
64 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 surveys. The availability of data on injuries is very relevant to the challenge of re- ducing injuries from workplace violence as such injuries are often nonfatal. The extramural research program is intended to be complementary to the intramural research program and focuses on all types of workplace violence. From 1996 to 2003, NIOSH funded 16 extramural grantsâ9 for risk factor research and 7 for intervention research. This research targeted several worker populations (retail workers, healthcare and social services workers, police officers, long-haul truckers, and domestic violence in the workplace), but focused mostly on the high-priority retail and health and social service worker populations. The committee found the TI Research Programâs work with the University of California, Los Angeles, which evaluated the effectiveness of a Workplace Violence Prevention Program in 314 Los Angeles retail establishments, to be particularly strong and relevant. Although not a specific target, vulnerable populations have been well addressed in both the intramural and the extramural research activities, particularly small businesses such as convenience stores and taxi drivers. Transfer Activities NIOSH and the TI Research Program engaged in several relevant proactive transfer activities for workplace violence. In 2002, NIOSH formed the Federal Interagency Task Force on Workplace Violence Research and Prevention. The meetings provide an opportunity for representatives of 20 federal agencies who are doing work or have an interest in workplace violence research to share informa- tion and form partnerships. NIOSH has also partnered with the Veterans Health Administration to evaluate workplace violence interventions in hospitals (NIOSH, 2007f, p. A-14). TI Research Program staff has provided technical assistance through the de- velopment of and participation in workplace violence task forces, workshops, and conferences. One notable effort was a TI Research Program partnership with the University of Iowa in 2000 to hold a workshop focusing on workplace violence intervention research. The conference resulted in the summary report âWorkplace Violence: A Report to the Nationâ16 and peer-reviewed papers (NIOSH, 2007f, p. A-15). The conference summary report led to a $2 million appropriation from Congress to the TI Research Program in FY 2002 for workplace violence research. TI Research Program staff also provided technical assistance to employers, em- ployees, and safety professionals through production of the DVD âViolence on the Job.â17 The DVD provides recommendations for preventing work-related 16â Available at http://www.public-health.uiowa.edu/Iprc/NATION.PDF. 17âNIOSH. 2004. Violence on the job (DVD). HHS (NIOSH) Publication No. 2004-100d.
P r o g r a m m a t ic R e l e v a n c e and I m pac t 65 homicides and assaults. More than 30,000 copies were distributed (NIOSH, 2007f, p. A-13; NIOSH, 2007g, p. 85). Several of the TI Research Programâs publications have been distributed to federal agencies, such as OSHA, the Office of Personnel Management, and the Federal Bureau of Investigation to assist them with the development of their own workplace violence recommendations (NIOSH, 2007g, p. 85), and thousands of copies of NIOSH publications on workplace violence have been disseminated. TI Research Program staff also responded to media requests for information about workplace violence information (NIOSH, 2007g, p. 85). Outputs The TI Research Program has a wide range of outputs in the area of workplace violence including intramural and extramural research publications, workplace violence prevention recommendations, staff interviews with media about work- place violence prevention, presentations at scientific conferences, stakeholder meet- ings, and national conferences. NIOSH and the TI Research Program have also sponsored or co-sponsored a number of workshops, conferences, and meetings on workplace violence. Several publications, such as the NIOSH Current Intelligence Bulletin âViolence in the Workplace: Risk Factors and Prevention Strategiesâ18 were groundbreaking, because they were among the first to highlight the problem of workplace violence on the national level (NIOSH, 2007g, p. 85). Several other publications addressed the high-risk population of retail workers. As stated previously, there has been a lack of surveillance of nonfatal injuries from workplace violence and the TI Research Programâs development of modules for use in three national surveys during 2002 to 2006 to collect nonfatal workplace violence injury data has helped to generate important new knowledge. Several outputs (such as the formation of the Federal Interagency Task Force on Workplace Violence Research and Prevention, research collaborations with universities, stakeholder meetings, and TI Research Program presentations at conferences) also build upon NIOSHâs institutional knowledge base and facilitate effective cross-agency and internal-external collaborations. Outcomes The evidence package documents several intermediate outcomes, including substantially increased attention to workplace violence by researchers since the late 18âJenkins, E. L. 1996. Current Intelligence Bulletin 57, Violence in the workplace: Risk factors and prevention strategies. HHS (NIOSH) Publication No. 96-100.
66 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 1980s (NIOSH, 2007g, p. 87). In addition, OSHA appears to have been influenced by TI Research Program outputs. OSHA cited the NIOSH Current Intelligence Bulletin âViolence in the Workplace: Risk Factors and Prevention Strategiesâ19 in its recommendations for taxi and delivery drivers as well as its guidelines for healthcare and community service workers. OSHA also cited TI Research Program surveillance and convenience store research in its recommendations for the pre- vention of workplace violence in late-night retail establishments (NIOSH, 2007g, p. 88). Although it has not been validated, these OSHA recommendations and guidelines are likely to have influenced workplace violence prevention policies in a number of states. TI Research Program staff also contributed to the development of a guide on workplace violence prevention for federal government agency planners by the Office of Personnel and Management (OPM, 1998), as well as guidelines for workplace violence prevention and a response by the American Society for Industrial Security (ASIS, 2006). As a possible end outcome of its work, the TI Research Program cites a signifi- cant decline in workplace homicides for 1993 to 2004. During that time, workplace homicides fell from 1,074 to 559, or almost 48 percent (NIOSH, 2007g, p. 89). The greatest decline was in the retail industry where the number of homicides fell almost 70 percent. A recent publication by NIOSH researchers (Hendricks et al., 2007) expands on this in reporting a significant decline in the rates of occupational homicide of approximately 6 percent per year between 1993 and 2002. This is slightly greater than the decline in rates of all U.S. homicides (5 percent per year) over the same period. The reduction in workplace homicides and the reduction in homicides overall are inextricably linked, and although the TI Research Program may have played a role in the reduction of workplace homicides, the degree of reduction that can be attributed to the TI Research Programâs workplace violence efforts versus the decline in homicides overall is unknown. Discussion The workplace violence prevention program appropriately focused on selected environments, collaborated with research partners, and achieved notable outcomes that have resulted in guidelines, policies, and progress toward reducing the burden of injuries and deaths due to workplace violence. Extramural research activities dominated after the 2002 federal earmark (75 percent of funds then went to out- side researchers). However, there appears to be a good balance of intramural and extramural activities targeting different work environments and different types of workplace violence. Through research and transfer activities, including the dis- 19âSee footnote 18 for reference.
P r o g r a m m a t ic R e l e v a n c e and I m pac t 67 semination of publications on workplace violence, NIOSH and the TI Research Program have helped make workplace violence a public health research priority. While it is difficult to draw direct inferences, selected occupational subgroups have experienced recent declines in workplace homicides. Replicating this progress for, and identifying technologies that address, other work environments; broad- ening the input from federal agencies; and continued transfer of research into practice, such as the work done in Los Angeles to test workplace violence interven- tions in convenience stores, will be vital to continued progress toward reducing the burden of workplace violence and death. Goal 4: REDUCE INJURIES AND FATALITIES DUE TO Machines The TI Research Program developed three subgoals for research aimed at re- ducing injuries and fatalities due to machines: 4.1. Reduce injuries and deaths caused by tractor rollovers by increasing the availability and use of effective rollover protective structures (ROPS) 4.2. Reduce worker injuries and deaths caused by paper balers 4.3. Reduce injuries and deaths caused by machines through the conduct of fatality investigations and the dissemination of prevention strategies Inputs More than half (991 out of 1,894) of the agricultural worker deaths from t Â ractor-related events that occurred between 1992 and 2001 were due to tractor overturns. One means of preventing deaths from tractor rollovers is the use of trac- tor ROPS. Newly manufactured tractors are built with ROPS and older models can be retrofitted. As of 2001, however, about 50 percent of tractors used on farms in the United States did not have ROPS. The TI Research Programâs work for subgoal 4.1 addresses barriers to the use of ROPS on tractors including cost and interfer- ence with low-clearance farming (which is needed in livestock, dairy, and fruit or nut tree farming). The TI Research Programâs work also addressed the problem of outdated anthropometry data for the agricultural populations that operate tractors (NIOSH, 2007h, pp. 97-98). From 1986 to 2002, two-thirds of the 43 U.S. workers who suffered fatal inju- ries while operating recycling industry balers were injured using horizontal balers that were baling paper and cardboard (NIOSH, 2007h, p. 104). Workers are at risk for this type of injury when attempting to remove jammed materials from balers that are not properly de-energized or safeguarded. An OSHA control of hazardous
68 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 energy (or âlockout-tagoutâ) standard (29 CFR 1910.147) establishes requirements for the control of unexpected energization or start-up of machines or equipment, and requires that procedures be developed that either prevent (lock) or warn work- ers (tag) of possible machine energization or energy release. However, lockout- tagout is not automatic and can be bypassed or forgotten. Subgoal 4.2 attempts to address this problem. The choice of FACE investigations (subgoal 4.3) as a focus reflects the inad- equate information in general surveillance systems identifying individual machines or types of machines associated with worker injuries. Even when injury and fatality data are available, information on the circumstances that led up to the incident, to identify risk factors and intervention options, is often missing. The TI Research Programâs FACE program for machines allows for the collection of detailed infor- mation on the types of machine injuries that are occurring, the identification of risk factors, and recommendations for prevention (NIOSH, 2007h, p. 107). The total intramural and extramural combined funding for the machines goal between FY1997 and FY2005 was $15,825,168 ($11,179,879 intramural and $4,645,289 extramural). Program funding had increased over time, especially for the extramural program. At its lowest in FY1997 the combined funding totaled $1,247,075, and at its peak in FY2005 funding reached $2,512,446. FTEs ranged from a low of 9.6 in FY1998 to a high of 14.8 in FY2002 (see Table 1-2). The committee found all three subgoals appropriate to the overarching chal- lenge of reducing machine-related injuries. The subgoals are narrow and focused on problem areas that the TI Research Program is capable of addressing with its funding and staff resources. Activities The TI Research Program has been conducting surveillance of farm worker injuries and fatalities and ROPS use on farms since 1994 when the Traumatic Injury Surveillance of Farmers (TISF) was developed. TISF was discontinued in 1997, but the TI Research Program has continued surveillance activities through the OISPA project (NIOSH, 2007h, pp. 98-99). A major activity for subgoal 4.1 was the design of cost-effective ROPS (CROPS) made from readily available commercial parts for use on different tractor models and auto-deploying ROPS (AutoROPS) for use in low-clearance farming. Both of these activities addressed important barriers to the use of ROPS on tractors. CROPS are a lower-cost alternative for consumers and thus could help address the cost-of-retrofitting barrier. In 2002, the TI Research Program built, designed, and tested CROPS that passed the Society of Automotive Engineersâ (SAE) SAE-J2194 industry ROPS standard (NIOSH, 2007h, p. 100). Building on this effort, the TI
P r o g r a m m a t ic R e l e v a n c e and I m pac t 69 Research Program and a ROPS manufacturer completed CROPS designs for five ad- ditional tractor models (NIOSH, 2007h, p. 100). In 1999, the TI Research Program developed AutoROPS as well as an overturn sensor that would monitor tractor operating conditions and deploy AutoROPS. The TI Research Program conducted laboratory and field tests of both devices. The first overturn test, conducted in 2000, showed the AutoROPS to be effective. The TI Research Program also used TISF data to conduct assessments of the cost-effectiveness of retrofitting tractors with ROPS, the results of which showed that retrofitting saves lives and money. One retrofitting assessment that included the cost of nonfatal injuries found that retrofitting tractors would save almost $490,000 per averted injury (NIOSH, 2007h, pp. 99-100). The TI Research Programâs work in addressing barriers to the use of ROPS is to be commended. On the manufacturing end, the TI Research Program has done excellent work to engage manufacturing partners in the ROPS development pro- cess. However, many decades-old tractors exist and the retrofitting of older tractors has occurred at a slower than optimal pace. Sometimes the barriers to retrofitting are not related to cost. For example, Hallman (2005) noted a nonfinancial âhassle factorâ as a significant obstacle to farmersâ willingness to retrofit. As discussed later in this report (see Chapter 3), the TI Research Program could, in the future, devote more resources toward research on how to facilitate faster adoption of the ROPS technology among farm workers.20 In response to the problem of outdated anthropometry data for tractor users, the TI Research Programâusing body scanning technologyâcollected three- dimensional body measurements of 100 farmers and farm workers. The program found the vertical clearance suggestion in the current SAE ROPS standard to be about 12 percent too short. The TI Research Program presented its findings to the SAE-J2194 Standard Committee in 2004, but there has not yet been a revision of the standard (NIOSH, 2007h, pp. 98-100). The major activity for subgoal 4.2 was the design and evaluation of a prototype system to automatically detect a jam in a recycling baler and safeguard workers by powering off. The system, called JamAlert, allows a jam to be cleared without the threat of unexpected energy release. The TI Research Program tested the prototype under a variety of operational conditions. Activities were collaborative; the TI Re- 20â Although not indicated in the evidence package, the committee learned that, in 2006, NIOSH provided funding to several university-based agricultural safety and health research centers to explore techniques to promote safe use of tractors. Under the initiative, the centers are studying some of the barriers to the use of ROPS on tractors, such as financial incentives to retrofit tractors with ROPS and the impact of changes to standards, regulations, and technology, and their effect on future ROPS availability. Several of the centers are also testing community-based social marketing techniques to improve safe use of tractors (NIOSH, 2006).
70 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 search Program worked with members of the ANSI Z245.5 Baler Safety Committee on design of the JamAlert prototype to ensure that it met or exceeded standards. It also consulted with equipment users, builders, and safety device manufacturers throughout the research process (NIOSH, 2007h, pp. 104-105). The committee found this activity to be highly relevant to address the bypassability limitation of the OSHA lockout-tagout standard requirements for machines. The major activity for subgoal 4.3 has been fatality investigations and dissemi- nation of recommendations. The TI Research Program conducted 45 machine- related fatality investigations from 1994 to 2006, collecting information on events that occurred prior to, during, and after fatal incidents in order to better under- stand contributing factors and develop recommendations for preventing similar incidents. More than 500 machine-related fatality investigations were conducted through the state-based FACE Program (NIOSH, 2008). Results of fatality investi- gations are put into narrative reports and made available on the NIOSH Web site (NIOSH, 2007h, p. 107). The TI Research Program also disseminated thousands of copies of NIOSH publications on the prevention of injuries from different types of machines (see following section). Although some types of machine-related injuries will be more relevant than others, the committee is pleased to see that the TI Re- search Program is looking at preventing diverse types of injuries beyond ROPS and paper balers. The committee supports the TI Research Programâs plans to include machine-related fatalities under the FACE Program in the future. Transfer Activities Transfer activity for subgoal 4.1 involved work with an equipment manufac- turer to develop new AutoROPS for the manufacturerâs zero-turn commercial mower. This activity was relevant, and working with industry partners gives them a stake in consumer use of this important safety measure. The TI Research Program petitioned the American Society of Agricultural and Biological Engineers (ASABE) to begin work on a performance standard21 for the AutoROPS as well. The standard is in draft form and has undergone a first review by ASABE (NIOSH, 2007h, p. 101). The JamAlert system for paper balers (subgoal 4.2) was not ready for transfer to the workplace and the TI Research Program is working with an industry partner to field test and commercialize this technology (NIOSH, 2007h, p. 105). In addition to FACE investigation reports (which are disseminated to target audiences based on the topic area), the TI Research Program disseminated thousands of copies of NIOSH documents (Alerts, Hazard Identification [ID] Bulletins, Workplace Solutions) on the prevention of injury from several different types of machines 21â ASABE-X599, Standardized Deployment Performance of an Automatic Telescoping ROPS for Agricultural Equipment.
P r o g r a m m a t ic R e l e v a n c e and I m pac t 71 (including cranes, paper balers, forklifts, and excavators or backhoe loaders) for subgoal 4.3. Dissemination was often done in collaboration with partners, facilitat- ing broader transfer. Outputs The TI Research Program authored 15 peer-reviewed articles as well as 19 con- ference presentations on subjects ranging from surveillance data, anthropometry of the farm worker population, economic analyses, and engineering analyses of performance and effectiveness of ROPS, AutoROPS, and CROPS. One manuscript on ROPS use and cost of retrofitting (Myers and Snyder, 1995) was referenced in at least 25 peer-reviewed journal articles. Economic analyses of ROPS retrofitting (Myers and Snyder, 1995; Pana-Cryan and Myers, 2000, 2002) were referenced in a minimum of 32 peer-reviewed journal articles based on a search of a series of manuscripts (NIOSH, 2007h, p. 101). The major output for subgoal 4.2 was the prototype JamAlert, for which the TI Research Program has filed an employee invention report and U.S. patent application. A paper on the laboratory testing that led to JamAlert design recommendations was presented at a 2005 American Society of Mechanical Engineers meeting. Another output was the NIOSH Alert âPreventing Deaths and Injuries While Compacting or Baling Refuse Material,â22 which provides recommendations for employers on prevention of injuries from working near refuse compacting and baling equipment (NIOSH, 2007h, p. 105). In terms of new technology, ROPS and JamAlert can be best characterized as the application of existing technology and do not appear to be particularly innovative. The committee found these outputs to be relevant to small businesses, and tech- nologies appear to be âuser-friendly,â although noncompliance may be a problem. Outputs for subgoal 4.3 were 45 investigative summary reports and 10 NIOSH documents addressing a variety of machine-related hazards. Outcomes The TI Research Program reports intermediate outcomes for each of the three subgoals for machines. Each of these intermediate outcomes contributes to the desired end outcome of a reduction in machine-related injuries. For subgoal 4.1, Colorado State University used TISF data to help target engineering research on the ability of pre-ROPS tractors to withstand forces of tractor overturn if ROPS were mounted on them and to identify the most common tractors by manufacturer and 22âNIOSH. 2003. Preventing deaths and injuries while compacting or baling refuse material. HHS (NIOSH) Publication No. 2003-124.
72 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 model for ROPS retrofit evaluations (NIOSH, 2007h, p. 101). A strong intermediate outcome for subgoal 4.2 was the contribution of the TI Research Programâs work on paper balers to revision of the ANSI Z245.5 Baling Equipment Safety standard. The evidence package reports that since the revision, baler manufacturers are providing purchasers of new balers with safety equipment and safety instructions that meet revised standard requirements. In addition, because hazards for which means of control are generally known are included under the General Duty Clause of the OSH Act,23 manufacturers should be meeting the standard (NIOSH, 2007h, p. 105). Events following the release of a number of NIOSH publications for sub- goal 4.3 are indicative of a positive stakeholder response. One example is that, after the dissemination of the Hazard ID Bulletin âIgnition Hazard from Drilling into Sealed Frames of Agricultural Equipment,â24 the plow manufacturer stopped using machine shop metal scrap for filling its equipment frames (because it was igniting) and began using clean stainless steel punch-out scrap. A number of publications, including a nationwide Future Farmers of America publication, summarized the hazard after the bulletin was released as well (NIOSH, 2007h, p. 111). The evidence package notes an end outcome for subgoal 4.3 of a steady deÂ cline from 1992 to 2005 in work-related fatalities caused by machines, plant and industrial powered vehicles, or tractors (16 percent decrease in number of deaths; 30 percent decrease in fatality rates) (NIOSH, 2007h, p. 111). Distribution of safety recommendations from fatality investigations and NIOSH publications to reduce machine-related injuries likely played some role in this decline. Discussion Machines are a common source of occupational injury and the TI Research Program is to be commended for its attention to this area. The committee found all subgoals for machines to be in line with the National Occupational Research Agenda (NORA I). Activities for tractor rollovers and paper balers were relevant, focusing on the development of new technologies (ROPS and JamAlert) to prevent worker inju- ries. The TI Research Program engaged in mutually beneficial collaborations to develop these technologies. In the future, the TI Research Program might consider extending its work on ROPS to technology adoption research to facilitate faster 23âPart(a) of the OSHA General Duty clause reads: (a) Each employer: (1) shall furnish to each of his employees employment and a place of employment which are free from recognized hazards that are causing or likely to cause death or serious physical harm to his employees; (2) shall comply with occupational safety and health standards promulgated under this Act (DOL, 2008). 24âNIOSH. 1998. Ignition hazard from drilling into sealed frames of agricultural equipment. HHS (NIOSH) Publication No. 98-146.
P r o g r a m m a t ic R e l e v a n c e and I m pac t 73 adoption of the ROPS technology by farm workers. The machines FACE Program acknowledges the diversity of machines and machine injuries in the workplace, and the important role that FACE investigations play in NIOSH contributions. The committee found the FACE Program to be the shining star of the research program for machines. In addition to ROPS and JamAlert, FACE investigations and NIOSH publi- cations appeared to impact intermediate outcomes. Particularly strong was the contribution of the TI Research Programâs work on paper balers to revision of the ANSI Z245.5 Baling Equipment Safety standard. Several FACE investigation out- puts appeared to be well received by stakeholders. Dissemination of these outputs by the TI Research Program likely contributed to declines in numbers and rates of machine-related fatalities between 1992 and 2005. GOAL 5: REDUCE ACUTE BACK INJURY NIOSH developed two subgoals for research aimed at reducing acute back injury: 5.1. Reduce acute injuries caused by patient handling 5.2. Evaluate interventions used to prevent acute injuries caused by material handling Inputs Planning inputs for subgoal 5.1 were data on the causes, costs, incidence, and prevalence of back injury due to patient lifting. Incidence and prevalence data show that nurses and other caregivers are at high risk for back injury from patient handling. The growth in demand for nurses coupled with their high injury rate, increases in the weight of patients, and the number of older workers in need of assistance with daily tasks were cited by the TI Research Program as causes for concern that back injury may become more of a problem for nurses and other caregivers over time (NIOSH, 2007i, p. 114). Evidence-based training of nurses and caregivers on best practices for patient handling is lacking as well. An outdated curriculum that promotes unsafe patient handling practices continues to be used (NIOSH, 2007i, p. 114). The only input cited by the TI Research Program for subgoal 5.2 was a need to increase the science on the effectiveness of back belts for preventing back injuries among materials handlers. Findings from prior studies of this issue showed con- flicting results and some studies had design limitations. The total intramural and extramural combined funding for back injury re- search in the TI Research Program between FY1997 and FY2005 was $10,257,669
74 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 ($7,329,287 intramural and $2,928,382 extramural). In terms of funding, this was the smallest of the TI Research Programâs eight goals for this period. Funding for both intramural and extramural research has generally decreased over the years. Combined funding was at its lowest in FY2004, when there was zero funding for extramural back injury research. FTEs have decreased over time as well, from a high of 15.7 in FY1998 to a low of 3.6 in FY2005 (see Table 1-2). The committee learned from TI Research Program staff that it plans to move work on acute back injury out of its program and into the musculoskeletal program.25 The decreases in funding may be reflective of that shift. Activities The major activity for subgoal 5.1 was an expansion of extramural work done in the early 1990s showing that a safe lifting program using mechanical lifts can be effective in nursing homes. To address the limitations of a small sample size and the relatively short follow-up period of 1 year in the 1992 study, the TI Re- search Program conducted a large nursing home intervention trial over a 6-year period. The TI Research Program collaborated with a St. Louis, Missouri, health system, which provided the study population. The study tested the effectiveness of a âbest practicesâ in safe lifting program, which was found to significantly reduce injuries for full- and part-time nurses (NIOSH, 2007i, p. 115). The com- mittee found this work to be relevant in that it addresses a knowledge gap. The TI Research Program also collaborated with a number of partners. In addition to the St. Louis, Missouri, health system, the TI Research Program worked with equipment manufacturers to test and evaluate the lifting equipment that was used in the intervention study. The primary activity for subgoal 5.2 was a large prospective cohort study conducted from 1996 to 1998 to evaluate the effectiveness of industrial back belts at preventing initial and recurrent low back injuries. The TI Research Program collaborated with Wal-Mart to enroll materials handlers with the highest lifting exposures from 160 Wal-Mart stores. Results from the study showed that neither frequent back belt use nor a store policy requiring the use of back belts reduced worker lower back injury or pain, and were suggestive to the TI Research Program that back belts could not be recommended for general use as protective technology in the workplace (NIOSH, 2007i, p. 123). The TI Research Program also conducted two laboratory evaluations of the same back belts used in the cohort study. Sig- nificant findings from the laboratory studies were that use of back belts decreases mean oxygen consumption, forward spine bending, and velocity of forward and 25âPersonal communication from N. Stout.
P r o g r a m m a t ic R e l e v a n c e and I m pac t 75 back spine bending. The committee sees these activities as relevant, because many work-related back injuries are caused by materials handling, and consistent with the subgoal 5.2 objective. However, in addition to industrial back belts, other in- terventions to prevent injuries due to materials handling could have been explored. The work in this area was collaborative; in addition to Wal-Mart, the TI Research Program worked with two universities and a survey research organization to ad- minister telephone surveys of study participants and manage data (NIOSH, 2007i, pp. 123-124). Transfer Activities The TI Research Program has engaged in a variety of transfer activities for subgoal 5.1. Findings from the work on safe patient lifting were published in the NIOSH document âSafe Lifting and Movement of Nursing Home Residentsâ26 and disseminated to thousands of nursing homes in the United States. The TI Research Program staff contributed to the work of a DOL-OSHA committee to synthesize evidence on safe patient lifting programs from 1998 to 2002. This work resulted in a publication of OSHA guidelines for nursing homes. To address the problem of outdated training curriculum for nurses, the TI Research Program has been work- ing with the National Council Licensure Examination Board to update safe patient lifting curricula and include the latest research findings in nursing licensure exams (NIOSH, 2007i, p. 116). The committee supports the TI Research Programâs plans to pursue additional work in this area, such as the evaluation of training curricula in nursing schools (NIOSH, 2007i, p. 119). The TI Research Program might also evaluate the impact of state legislation to promote safe patient handling. There did not appear to be much proactive transfer activity for subgoal 5.2. The Wal-Mart study was published in the Journal of the American Medical Association (JAMA) (Wassell et al., 2000). The laboratory evaluation studies were published in Applied Ergonomics (Bobick et al., 2001) and Spine (Giorcelli et al., 2001). NIOSH maintains a summary of findings on back belt research on its Web site. Outputs For subgoal 5.1, outputs included peer-reviewed journal articles, NIOSH publi- cations, conference proceedings and presentations, and chapters in nursing student textbooks. Outputs build internal and external knowledge about back injury due to patient handling and support research and education capacity. For example, the 26âCollinset al., 2006. Safe lifting and movement of nursing home residents. HHS (NIOSH) Pub- lication No. 2006-117.
76 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 âSafe Lifting and Movement of Nursing Home Residentsâ27 presents a business case to nursing home workers interested in instituting a safe patient lifting program. The work to update nursing training curricula helps to ensure that nurses are provided an evidence-based education on patient lifting. The committee finds that outputs could have better accommodated Spanish-speaking workers who make up increas- ing numbers of nursing home employees. The outputs for subgoal 5.2 were peer-reviewed journal articles from the Wal- Mart and laboratory studies on industrial back belts (NIOSH, 2007i, p. 124). In the cohort study, the TI Research Program found that neither frequent back belt use nor a store policy that employees must wear back belts was associated with a reduced incidence of back injury claims or low back pain (NIOSH, 2007i, p. 123). This output adds to the evidence that back belts may do little to prevent back injury caused by materials handling. The committee noted a reduction in outputs for the TI Research Program back injury research over time that may reflect NIOSHâs plans to combine its acute back injury research with chronic, musculoskeletal back injury research. The committee believes that this is in NIOSHâs best interest. Outcomes TI Research Program work on back injuries has resulted in workplace changes through the passage of legislation. Patient handling research was used in support of the passage of safe patient handling legislation in six states from 2005 to 2006 (NIOSH, 2007i, pp. 116-117).28 Legislation addressed safe patient handling poli- cies in hospitals and nursing homes, provision of lifting equipment to hospitals, education and training of employees, and safe patient handling research, among other things. Six additional states have proposed similar legislation based on TI Research Program work. The American Nurses Association is using TI Research Program findings on patient handling in its âHandle with Careâ program, which is a national effort to reduce musculoskeletal injuries among nurses due to patient handling (NIOSH, 2007i, p. 117). The TI Research Program cites a decrease in incidence rate for sprains and strains in hospitals and nursing homes from 1992 to 2005, more specifically in cases where lifting patients was the source of the injury, as evidence of progress toward an end outcome (NIOSH, 2007i, pp. 117-118). A direct connection cannot be made between the TI Research Programâs work and this decline. However, the 27âSeefootnote 26 for reference. 28âLegislationincluded Texas Senate Bill 1525; Washington House Bill 1672; Hawaii House Concur- rent Resolution No. 16; Rhode Island House 7386 and Senate 2760; Ohio House Bill 67; and New York companions Bills A07641 and S04929.
P r o g r a m m a t ic R e l e v a n c e and I m pac t 77 committee agrees that the TI Research Program has provided much of the knowl- edge base that would allow workplaces to make changes that result in reductions in musculoskeletal injuries from lifting patients. According to the evidence package, publication of the Wal-Mart study in JAMA had an impact on the use of back belts in a number of large retail outlets. Many stores withdrew store policies requiring the use of back belts and some stores began to use other back injury prevention measures (NIOSH, 2007i, p. 124). Because the TI Research Programâs work in materials handling led to the knowledge that back belts were ineffective, the committee did not expect an end outcome for this subgoal. Discussion The TI Research Programâs work on back injuries is very relevant. Back injuries continue to be among the most serious occupational problems in terms of injury and lost time. Both subgoals are aligned with NORA I priorities. The major activity for subgoal 5.1 addressed a research gap by evaluating a safe patient lifting best-practices intervention. Activities for subgoal 5.2 were nar- rowly focused on evaluating back belts and patient lifting devices. A well-designed cohort study added to the evidence on the effectiveness of back belts. However, the committee feels the program would have been stronger had other intervention strategies to address manual materials handling also been evaluated. Outputs for subgoal 5.2 were comprehensive and add to the knowledge about back injury due to patient lifting. Intermediate policy outcomes for this subgoal (legislation in six states) were particularly strong in that they have the potential to result in workplace changes to reduce risk of back injuries associated with patient lifting. GOAL 6: REDUCE INJURIES AND FATALITIES AMONG WORKERS IN ALASKA The TI Research Program developed an Alaska goal area after discovering in the late 1980s that the state had a higher worker fatality rate than any other U.S. state. From 1980 to 1989, the annual traumatic occupational fatality rate in Alaska was nearly 35 per 100,000 workers, or almost five times the annual U.S. average of 7 per 100,000 workers (NIOSH, 2007j, p. 126). NIOSH established the Alaska Field Station (AFS) in Anchorage in 1991 with a goal of reducing Alaskaâs high rate of traumatic occupational fatalities. The work was supported by a 1990 congressional directive for NIOSH to âengage in research, prevention, and outreach activities to reduce these unacceptably high levels of preventable occupational injuries.âÂ
78 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 developed three subgoals for research aimed at re- ducing 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 Inputs One of the first efforts of the TI Research Program in Alaska was to establish a comprehensive occupational injury surveillance system. Although the establish- ment of this system in 1991 predates the period of the committeeâs assessment, the surveillance work continues and is key to current activities. The Alaska Occupa- tional Injury Surveillance System (AOISS) and the Alaska Trauma Registry (ATR) were the result of partnerships between federal and state agencies. Also in 1991, the TI Research Program formed the Alaska Interagency Working Group (IAWG) for the Prevention of Occupational Injuries to provide a broader understanding of occupational injuries in the state and to enable rapid response to emerging problems. The IAWG is made up of members from state and federal agencies, local entities, industry associations, and the University of Alaska at Anchorage. There are IAWG subgroups for Alaska commercial fishing safety, aviation, and construction. The IAWG has facilitated the TI Research Programâs work in Alaska, including the development of AOISS (NIOSH, 2007j, pp. 128-129). Inputs specific to subgoal 6.1 were data on risk factors for fatal and nonfatal injuries among commercial fishers. Fisherman fatalities were often found to be due to the sinking of vessels and crew members falling overboard, while nonfatal injuries more often occurred on deck during deployment and retrieval of fishing gear. The TI Research Program also wanted to evaluate commercial fishing indus- try policies that had not yet undergone evaluation, such as the 1988 Commercial Fishing Industry Vessel Safety Act (CFIVSA)29 (NIOSH, 2007j, p. 127). The TI Research Program pursued subgoal 6.2 based on data showing that, over an 18- month period between January 1992 and June 1993, 6 of 25 helicopters used for logging in southeast Alaska crashed, resulting in 9 deaths and 10 severe injuries. Investigations by the National Transportation Safety Board (NTSB) had shown improper operation and/or vehicle maintenance to be a problem in all of these crashes (NIOSH, 2007j, p. 137). Alaska is dependent on air transportation for transport of goods and passen- gers to and from areas not accessible by other means, yet aviation is a high-risk 29âP.L. 100-424, September 9, 1988, 100th Congress: To provide for the establishment of additional safety requirement for fishing industry vessels, and for other purposes.
P r o g r a m m a t ic R e l e v a n c e and I m pac t 79 industry in Alaska due to the stateâs unique terrain and weather challenges as well as incomplete radar coverage (NIOSH, 2007j, p. 137). From 1990 to 1999, 401 people died in Alaskan aviation crashes and almost 40 percent of fatalities were of work- ers on the job. Controlled flight into terrain (CFIT)30 accounted for an average of five fatal occupational crashes per year in Alaska for this period (NIOSH, 2007j, p. 141). In addition to these data, the TI Research Programâs work for subgoal 6.3 is influenced by legislation passed by Congress in 2000 (P.L. 106-69) to reduce oc- cupational aircraft crash fatalities by 50 percent by the end of 2009. This legislation resulted in formation of the Alaska Interagency Safety Initiative to improve air safety through the collaborative efforts of the TI Research Program, the FAA, the National Transportation Safety Board, and the National Weather Service (NIOSH, 2007j, p. 141). Stakeholder input is a staple to the Alaska program, in part through the IAWG. However, there was no mention of stakeholder input from labor organizations or other worker representatives in the materials reviewed. In addition, the commit- tee would have liked to have seen more evidence of collaborative involvement of Native Alaskan groups included. The total intramural and extramural combined funding for the Alaska workers program between FY1997 and FY2005 was $14,089,400 ($10,932,226 intramural and $3,157,174 extramural), making it one of the smaller programs for this period in terms of funding (see Table 1-2). Extramural funding decreased each year from 2001 to 2005, and in 2005, no funds were allocated for extramural research. FTEs ranged from a low of 6.6 in FY1999 to a high of 12.8 in FY2002, and have been relatively stable since 2001. Activities Activities for subgoal 6.1 were broad (including surveillance, risk factor in- tervention, and policy evaluation research) and relevant to reducing traumatic injuries among commercial fishermen. The TI Research Program is engaged in continuous collection and analysis of surveillance data from the AOISS and the ATR to identify commercial fishing hazards and track progress in the attainment of program goals. An impressive focused intervention effort was a 2000 project to find and disseminate solutions to fatal and nonfatal injuries that occur on fishing vessel decks. Working with the North Pacific Fishing Vessel Owners Association, the TI Research Program conducted focus groups with crab fishermen on deck safety problems and toured vessels to view problems and discuss potential modifications 30âCFIT is an accident in which an airworthy aircraft inadvertently flies into terrain, an obstacle, or water. Pilots are generally unaware of danger until it is too late.
80 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 (NIOSH, 2007j, p. 129). This work resulted in a crab fishermen deck safety hand- book31 and a 1:10-scale deck safety model for use at industry trade shows. Another important intervention activity was the development of an emergency stopâor e-stopâsystem by the NIOSH Spokane research lab, which allows fishermen to stop a winch quickly when entangled. The TI Research Program worked with a partner on design, installation, and testing of the system in one vessel. A TI Research Program evaluation of the CFIVSA showed that, since passage of the act, there has been a decline in the number of fatalities among commercial fishermen but not in the number of vessels sunk. This activity resulted in recommendations to modify the CFIVSA approach to focus on the prevention of disasters rather than the use and availability of safety equipment during and after disasters and in the NIOSH document âCommercial Fishing Fatalities and Prevention Strategies in Alaska,â32 which describes risk factors and prevention strategies for commercial fishing deaths in Alaska (NIOSH, 2007j, pp. 129-130). The TI Research Program arranged an emergency meeting of the Alaska IAWG in 1993 upon discovering a series of helicopter-logging accidents. Meeting partici- pants (FAA, NTSB, OSHA, the U.S. Coast Guard [USCG], the Alaska Department of Labor [AKDOL], and the Alaska Department of Health and Social Services) developed recommendations to improve helicopter-logging safety and called for industry-wide standards and procedures. In response to the meeting, the FAA and AKDOL inspected all helicopter-logging sites and shut down some because of irregularities (NIOSH, 2007j, p. 137). The TI Research Programâs activities for subgoal 6.2 for the evaluation period have been a continuation of the IAWG efforts to generate recommendations for the logging industry and to transfer those recom- mendations to industry (see following section). For example, between March 1995 and March 1997, the TI Research Program cosponsored three Helicopter-Logging Safety Workshops in Alaska for capacity building. Attendees from government, industry, academia, and insurance developed and refined recommendations to be provided to helicopter-logging industry representatives (NIOSH, 2007j, pp. 137- 138). There have been no helicopter-logging crashes in Alaska since 1996. The committee finds work by the TI Research Program and partners to maintain this statistic through continued recommendation development and dissemination to be relevant and important. Activities for subgoal 6.3 seemed to focus predominately on transfer and are described in the section below. One risk factor effort examined practices and at- titudes of Alaskan commercial commuter and air taxi operators and their pilot and 31âJensen Maritime Consultants. 2002. Deck safety for crab fishermen. Available at: http://www. jensenmaritime.com/images/stories/crabdeck.pdf (accessed August 6, 2008). 32âNIOSH. 1997. Commercial fishing fatalities and prevention strategies in Alaska. Current Intel- ligence Bulletin (CIB) #58. HHS (NIOSH) Publication No. 97-163.
P r o g r a m m a t ic R e l e v a n c e and I m pac t 81 companiesâ fatal accident rates (NIOSH, 2007j, p. 142). Results showed that pilots at operations with high fatalities had less overall career flight experience but worked more hours per week. Another effort evaluated factors related to crash survivability (e.g., post-crash fire, distance from airport). Transfer Activities The committee found all transfer activities for the Alaska program to be rel- evant and sensitive to stakeholder needs. Subgoal 6.1 transfer activities involved technical assistance from TI Research Program staff. In 2005, the TI Research Program assisted the USCG with an evalu- ation of the USCG Dockside Pre-season Boarding Program. Findings suggested the program had likely been effective; from 1999 (when the program was imple- mented) until 2005, there were three fatalities in the crab fishery, compared to an average of seven deaths per year in years prior to 1999 for which data were captured (NIOSH, 2007j, p. 129). TI Research Program staff also provided expert testimony to the National Research Council (NRC) Ocean Studies Board on safety implica- tions of individual fishing quotas33 for the halibut-sablefish fishery in 1997 and provided a demonstration of the e-stop system at a large U.S. commercial fishing trade show. The crab fishermen deck safety handbook is posted on several safety Web sites, and more than 4,000 copies were proactively distributed to fishermen in the Pacific Northwest. Transfer activities for subgoal 6.2 involved the dissemination of recomÂmenÂ dations and workshop proceedings. In addition to the recommendations from the 1993 meeting, the IAWG disseminated recommendations from the three H Â elicopter Logging Safety Workshops (NIOSH, 2007j, p. 138). The TI Research Program has engaged in a wide range of relevant and pro- active transfer activities for subgoal 6.3. These include training and information dissemination at seminars and meetings, dissemination of research articles and recommendations, and staff participation on Alaska safety committees. Among the strongest of these activities were aviation safety seminars and meetings targeting passenger and flight crew audiences. In 2000 and 2001, the TI Research Program organized two free Aviation Passenger Safety Seminars and gave presentations on topics such as aviation safety for passengers, training to learn basics of flying and landing a small aircraft (if pilot becomes incapacitated), and incorporation of safety measures into a company-air carrier contract for transportation of employees. Based on intermediate outcomes for this subgoal (described below), this effort 33âIndividual fishing quotas were implemented as an element of fishery management for the Âhalibut- sablefish fisheries in 1995. They set an allowable catch limit for vessel owners and a time frame in which they have to catch their limit (NIOSH, 2007j).
82 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 seems to have been very well received. TI Research Program staff has also pre- sented aviation safety information to pilots and industryâfor example, at NIOSH- sponsored Aviation Safety Alliance meetings for pilots and industry in 2003 and 2006. The TI Research Program provided findings from crash survivability research to safety organizations and regulatory agencies so they can develop safety programs (NIOSH, 2007j, p. 142). Outputs Outputs for subgoal 6.1 were NIOSH publications, journal articles, recommen- dations, and a new technology intervention (e-stop). In addition, the TI Research Program and partners organized conferences and workshops on commercial fishing safety. These included two Fishing Industry Safety and Health (FISH) Workshops and three International Fishing Safety and Health (IFISH) Workshops, which were important for bringing together representatives and organizations with a stake in commercial fishing safety (NIOSH, 2007j, p. 130). Proceedings of the FISH and IFISH conferences were published as NIOSH documents. Outputs for subgoal 6.2 were recommendations from the IAWG and Helicopter Logging Safety Workshops, workshop proceedings, and three publications (an ar- ticle in Morbidity and Mortality Weekly Report,34 a chapter in the book Safety and Health in Agriculture, Forestry, and Fisheries,35 and the NIOSH report âHelicopter Logging Safetyâ36). Outputs for subgoal 6.3 included meetings and seminars, recommendations, journal articles, and NIOSH publications (one presenting results of an analysis of survey data called âSurvey and Analysis of Air Transportation Safety Among Air Carrier Operators and Pilots in Alaskaâ37). Outcomes The evidence package noted intermediate and end outcomes for each of the Alaska program subgoals. 34âCDC. 1994. Risk for traumatic injuries from helicopter crashes during logging operationsâ Southeastern Alaska. Morbidity and Mortality Weekly Report 43(26):472-475. 35âLangley, R. L., R. McLymore, W. J. Meggs, and G. T. Roberson. 1997. Epidemiology and prevention of helicopter logging injuries. In Safety and Health in Agriculture, Forestry, and Fisheries. Government Institutes. 36âNIOSH. 1998. Helicopter logging safety: Alaska interagency working group for the prevention of occupational injuries. HHS (NIOSH) Publication No. 98-147. 37âNIOSH. 2007. Survey and analysis of air transportation safety among air carrier operators and pilots in Alaska. HHS (NIOSH) Publication No. 2007-102.
P r o g r a m m a t ic R e l e v a n c e and I m pac t 83 One of the strongest intermediate outcomes for subgoal 6.1 was work by the Alaska USCG to design and implement the Dockside Pre-season Boarding Program, which was based on work done at the TI Research Programâsponsored 1997 FISH Workshop. USCG vessel safety examiners developed the âat-the-dockâ boarding program to identify and correct safety hazards known to exist in the Bering Sea crab fisheries.38 The program involves the examination of vessels for stability and lifesaving equipmentâas required by CFIVSAâprior to the opening of the crab fishery. If an examination shows that a vessel is not loaded properly or if there is a lack of lifesaving equipment, the vessel is not able to leave port. Another strong intermediate outcome was use of the NIOSH document âCom- mercial Fishing Fatalities and Prevention Strategies in Alaskaâ39 by a USCG task force in 1998 to develop a national plan for fishing vessel safety. In the task forceâs final report, called âLiving to Fish, Dying to Fish,â40 the USCG adopted 8 of the 11 recommendations from the NIOSH document. The NIOSH document has been used by other organizations as a resource on commercial fishing vessel safety as well. An end outcome noted in the evidence package for subgoal 6.1 is a decline in numbers of deaths among commercial fisherman by 74 percent between 1990 and 2005, and a 51 percent decline in the annual fatality rate during this same period. The overall reduction in fatalities has been driven to a large extent by reductions in fatalities in crab fishery, for which the fatality rate dropped by more than 50 percent comparing rates since 2000 to those of the 1990s (NIOSH, 2007j, p. 132). Although the committee cannot say with certainty that these declines are due to the TI Research Programâs work, it agrees that outputs and intermediate outcomes of the TI Research Program and partners, particularly those related to safety for crab fishermen, likely played a role. An important intermediate outcome for subgoal 6.2 was the adoption of heli- copter safety guidelines developed by the 1996 Helicopter Logging Safety Committee in the operational procedures of 27 helicopter logging companies. The eviÂdence package also notes an end outcome for this subgoal. After the meeting of the Alaska IAWG and the helicopter logging site inspections in 2003, no helicopter logging crashes or fatalities occurred until 1996, when one crash took place. No additional crashes have occurred since the 1996 crash despite extensive logging between 1994 and 1999 (NIOSH, 2007j, p. 139). The committee agrees that the rather sharp de- cline in helicopter logging crashes is likely tied to the TI Research Programâs work 38âThese fisheries were chosen based on NIOSH findings identifying the crab fishery as having the highest fatality rate of any fishery in Alaska. 39âNIOSH. 1997. Current Intelligence Bulletin 58, Commercial fishing fatalities and prevention strategies in Alaska. HHS (NIOSH) Publication No. 97-163. 40âUSCG. 1998. Living to fish, dying to fish. Available at: www.uscg.mil/hq/gm/moa/docs/fvctf.doc (accessed July 23, 2008).
84 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 with partners to develop and disseminate recommendations to improve helicopter logging safety (NIOSH, 2007j, p. 138). TI Research Program outputs for subgoal 6.3 contributed to a number of im- portant educational programs and materials. Information presented by TI Research Program staff at the Aviation Passenger Safety Seminars in 2000 and 2001 was in- corporated into the FAA Circle of Safety consumer education program, which aims to educate passengers on their role in aviation safety in Alaska. Information from the seminars and TI Research Program-CFIT research was also incorporated into an FAA informational handout for pilot training. The Alaska Airmenâs Association and the FAA used TI Research Program recommendations to develop public ser- vice announcements and a crash survival training video. Results from the pilot and operator survey were used by the FAA Flight Standards Division to review interven- tion programs and by the nonprofit Medallion Foundation to focus pilot training (NIOSH, 2007j, p. 144). End outcomes noted by the TI Research Program for sub- goal 6.3 are declines in aviation crashes and pilot fatalities, comparing data from the 1990s to those since the start of the Alaska Interagency Safety Initiative (2000-2005); occupational fatalities in aviation crashes decreased 44 percent and the pilot fatality rate decreased 53 percent. In addition, the average number of fatal occupational ac- cidents due to CFIT declined by 60 percent, from an average of five fatalities per year from 1990 to 1999 to an average of two fatalities per year from 2000 to 2005. The TI Research Program acknowledges that these changes came about because of work done in concert with other agencies, organizations, and industry (NIOSH, 2007j, p. 144). It is impossible to estimate the degree to which the TI Research Programâs work contributed to these reductions. However, increased awareness of aviation safety through the TI Research Program and partner consensus building, program outputs, and intermediate outcomes likely played some role. Discussion The committee found all elements of the Alaska program to be based on rel- evant statistics and designed to address important risks in various Alaska work sites. Stakeholder and worker participation seems to be a staple of the Alaska program, although there was no mention of stakeholder input from labor organizations or other worker representatives. There was a surprising lack of collaborative involve- ment of Native Alaskan groups. Activities have centered around an effective model for targeted, applied re- search using a public health approach at the state level that develops and uses good surveillance data, targets the most significant problems, builds partnerships, develops diverse solutions (technical, policy, training, etc.), implements promis- ing interventions, evaluates impact, and broadly disseminates results. A significant
P r o g r a m m a t ic R e l e v a n c e and I m pac t 85 factor in the success of the program, in addition to those listed above, is the invest- ment of sufficient resources, particularly qualified staff. The committee notes that it would be useful to see more interaction among the Alaska program and other researchers in NIOSH so that those other researchers can learn from the AFS ap- proach to applied research and the Alaska team can tap into other research skills at NIOSH (as well as extramural investigators). There has been good transfer through technical assistance and dissemination of documents and recommendations, with clear relevance to reducing traumatic injury in the fishing, logging, and aviation in- dustries. In addition to continued work to target workers in Alaska, the committee is of the understanding that the AFS staff will help address problems with similar industries in the Pacific Northwest and other regions of the United States. The TI Research Program has documented impressive intermediate and end outcomes for each subgoal. The end outcomesâreductions in deaths of com- mercial fishermen in Alaska, in crashes of helicopters flying in logging operations, and in pilot fatality ratesâgenerally were likely tied to program outputs and in- termediate outcomes. GOAL 7: REDUCE INJURIES AND FATALITIES TO EMERGENCY RESPONDERS NIOSH developed three subgoals for research aimed at reducing 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. Improve protection for emergency workers responding to large- scale disasters and terrorist attacks Inputs Congress directed NIOSH to engage in firefighter safety research (subgoal 7.1) with a special appropriation of $2.5 million in 1998 (NIOSH, 2007d, p. 148). The specific language was: âThe conference agreement provides increases above the 1997 level for occupational safety and health for the following activities: intramural research at the Morgantown, West Virginia facility; the fire fighter safety initiative; and the national occupational research agenda.â41 Planning inputs into subgoal 7.2 were findings from fatality investigations showing inadequate protection for firefighters and other EMS (emergency medi- cal services) workers injured in patient compartments during crashes (NIOSH, 41âPersonal communication from N. Stout.
86 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 2007d, p. 150). Lap belts in ambulance compartments do not allow EMS workers the mobility needed to access patients and medical equipment. Therefore, the lap belts may not be used. The TI Research Program also noted the problem of EMS equipment often carried unsecured in ambulance patient compartments, which can become projectiles in the event of a crash. Subgoal 7.3 addresses the need to learn from disasters and terrorist attacks so that response to such occurrences in the future is safer for emergency response workers. In planning its work on emergency responders, the TI Research Program re- ceived input from fire unions, fire departments, state organizations, and ambulance manufacturers. Workshops with these groups were also held to gain input in dis- semination efforts. This interaction appears to have been productive. The total intramural and extramural combined funding for this project for the period FY1997-2005 was $15,780,346 ($12,090,779 intramural and $3,689,567 ex- tramural). In FY1997 this was the smallest of the eight goals, with combined fund- ing of $166,680 (see Table 1-2). However, funding has increased and, since FY1999, this goal has been one of the TI Research Programâs larger research programs. FTEs ranged from a low of 2.5 in FY1998 to high of 18.5 in FY2003. Activities In response to the congressional appropriation for firefighter safety research, the TI Research Program initiated the Fire Fighter Fatality Investigation and Pre- vention Program (FFFIPP) in 1998. This program has been the focus of the TI Research Programâs research activities on firefighter safety. The committee finds this activity to be highly relevant to better understanding the risk factors for fire- fighter line-of-duty deaths and the development of interventions. The FFFIPP involves onsite investigations of firefighter line-of-duty deaths to generate reports describing the circumstances that led to the incidents. Recommendations to pre- vent similar incidents in the future are developed based on report findings. From 1998 to 2006, the TI Research Program conducted 366 investigations of incidents resulting in firefighter deaths (NIOSH, 2007d, p. 148). The TI Research Programâs firefighter safety activities have been very collaborative. One strong example is a TI Research Program-United States Fire Administration memorandum of under- standing on how âto identify collaborative efforts to improve safety and health and health conditions for firefighters throughout the United Statesâ in order to facilitate the use of TI Research Program products in firefighter safety training (NIOSH, 2007d, p. 149). Activities for subgoal 7.2 were relevant and addressed subgoal inputs. In ad- dition, many ambulances are based in fire departments, making this work ap- plicable to both firefighters and other EMS workers (NIOSH, 2007d, p. 157). The
P r o g r a m m a t ic R e l e v a n c e and I m pac t 87 TI Research Program conducted laboratory research with a number of partners to evaluate mobile occupant restraint systems42 using computer modeling and dynamic testing (NIOSH, 2007d, p. 158). The TI Research Program also worked with a contractor on a performance evaluation of energy-absorbing foams, the findings of which will be used to create recommendations for the EMS industry, ambulance manufacturers, and standards-setting bodies. The TI Research Program used a contractor to evaluate crashworthiness of EMS medical equipment carried in ambulance compartments (NIOSH, 2007d, p. 159). Another important aim of the TI Research Programâs work on ambulance safety has been to describe and quan- tify the scope of injuries among EMS workers. Efforts to address this gap in data included an analysis of data from the NHTSA Fatality Analysis Reporting System, which identified 300 fatal ambulance crashes resulting in deaths of 27 EMS workers from 1991 to 2000. The TI Research Program has also been working with a large EMS provider, American Medical Response, to evaluate the providerâs employee injury and compensation database to assess nonfatal injuries to EMS workers due to crashes (NIOSH, 2007d, p. 158). Subgoal 7.3 was initiated in the aftermath of the September 11, 2001, terrorist attacks. One effort in this area was NIOSH and RAND (Research and Development Corporation) individual and group interviews of emergency response workers to gather input into a collaborative study of occupational safety and health manage- ment practices in major disaster response. In 2003, NIOSH and RAND also held a workshop of experts in emergency response and occupational safety and health in order to gather expert opinion on training, hazard assessment, surveillance of emergency workers, and other issues (NIOSH, 2007d, p. 166). Transfer Activities The TI Research Program investigations of firefighter fatalities (subgoal 7.1) have resulted in a number of educational documents and journal articles that summarize hazards and recommend prevention measures. Dissemination of these products occurs primarily through the TI Research Program-FFFIPP Web site, which has links to all fatality investigations and other TI Research Program publications. The TI Research Program also engages in proactive transfer of products on firefighter safety. For example, there are periodic mass mailings 42â âMobile occupant restraints employ worker-worn harnesses that are tethered to the structure of the patient compartment. The tethers are stored on retractor reels, which unwind as the occupant moves away from the seat and wind up as the occupant moves back into the seat. In the event of a crash, the retractor reels automatically lock, providing restraint against crash forces. This arrange- ment allows EMS workers the mobility needed to access patients while simultaneously providing crash protectionâ (NIOSH, 2007d, p. 157).
88 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 (approximately one per year) of investigation reports to more than 30,000 U.S. fire departments. Firefighter safety recommendations have been disseminated to equipment Âmanufacturers, municipalities for organization and coordination of fire services and building safety requirements, and research organizations for de- velopment and enhancement of safety technology (NIOSH, 2007d, pp. 150-151). TI Research Program staff has provided technical assistance through participa- tion on several National Fire Protection Association (NFPA) technical com- mittees developing standards to support firefighter safety and health.43 The TI Research Programâs Personal Protective Technology Program staff also conducted physiological-ergonomic testing of a prototype personal protective equipment firefighter ensemble as part of Project HEROES (Homeland Emergency Response Operational Equipment Systems) (NIOSH, 2007d, p. 152). For subgoal 7.2, the TI Research Program has given briefings of tests of mobile occupant restraint systems to research partners. The TI Research Program also provided data packages to partners to support additional research and develop- ment. According to the evidence package, the TI Research Program is still working with a contractor to finalize and publish ambulance crash test findings (NIOSH, 2007d, p. 161). The committee supports the TI Research Programâs continued analysis and publication of crash data and encourages dissemination of findings for use by others for ambulance design improvements. The contractor evaluating the crashworthiness of EMS equipment in ambulance compartments is continuing work to develop procedures to quantify crash performance of mounting systems (NIOSH, 2007d, p. 159). A major transfer activity for subgoal 7.3 was the dissemination of the RAND- TI Research Program publication âProtecting Emergency Responders, Volume 3: Safety Management in Disaster and Terrorism Response,â44 which was released June 2004. The report was launched by press release and presented at a congressional briefing. It was then disseminated by mail to state emergency management and public safety officials, public health and federal agencies, state OSHA programs, and others. The report was also distributed at conferences, trade shows, and exhibits and is available online (NIOSH, 2007d, pp. 167-168). Other transfer work for subgoal 7.3 was TI Research Program staff assistance with injury and illness surveillance following natural and human-caused disasters. In the aftermath of the September 43âThese standards were NFPA 1500 (Standard on Fire Department Occupational Safety and Health Programs), NFPA 1981 (Standard on Open-Circuit Self-Contained Breathing Apparatus for Fire and Emergency Services), NFPA 1982 (Standard on Personal Alert Safety Systems [PASS]), and NFPA 1989 (Standard on Breathing Air Quality for Fire and Emergency Services). 44âNIOSH. 2004. Protecting emergency responders, volume 3: Safety management in disaster and terrorism response. HHS (NIOSH) Publication No. 2004-144, RAND Publication No. MG-170.
P r o g r a m m at i c R e l e va n c e and I m pac t 89 11, 2001, attacks, for example, TI Research Program staff facilitated dissemination of rescue worker injury and illness data to other NIOSH divisions for analysis. TI Research Program staff also designed data collection tools for capturing responder injuries and illnesses as a part of a disaster response worker registry, and provided modular data collection tools that could be used or adapted to monitor injury and illness of workers following the 2004 tsunami in Southeast Asia and Hurricane Katrina in 2005 (NIOSH, 2007d, pp. 165-166). Outputs In its work on firefighters, the TI Research Program has produced a large number of fatality investigation reports on individual firefighter deaths and has presented its findings at conferences and meetings as well as in trade publications. Fatality investigation findings led to development of a number of educational ma- terials and journal articles on firefighting hazards such as electrical hazards, and hazards to firefighters involved in live-fire training and working along roadways, to name a few (NIOSH, 2007d, p. 151). The TI Research Program has written two peer-reviewed publications, and one more has been submitted in the area of improving protection of ambulance workers in patient compartments. There were a number of conference papers and presentations (NIOSH, 2007f, p. A-46). Findings from several fatality investiga- tions of ambulance crashes have been published and are available online. NIOSH also funded several crash investigative reports by NHTSA that are available on the NHTSA Web site. The TI Research Program produced no peer-reviewed publications in the area of improving protection for emergency workers responding to large-scale disasters and terrorist attacks. The major output of this program was the NIOSH-RAND work on emergency responders. Several NIOSH publications related to disaster safety were also produced. Outcomes There are several intermediate outcomes for the TI Research Programâs work on emergency responders that demonstrate program impact. End outcomes were not reported for any of the subgoals. For subgoal 7.1, findings from four FFFIPP investigative reports involving problems with Personal Alert Safety System (PASS) alarms influenced the revi-
90 T r a u m a t i c I n j u r y R e s e a r c h at NIOSH sion of the NFPA 1982 PASS standard.45 One FFFIPP investigation was cited in the justification for New York Stateâs Bradleyâs Law,46 which prohibits the use of people to play the role of victim under live-fire conditions in fire safety training (NIOSH, 2007d, p. 153). As evidence that the FFFIPP is impacting the workplace, a preliminary evaluation study of the program indicates that recommendations are being used to update safety training programs in thousands of fire departments (NIOSH, 2007d, p. 153). Respirator standards for firefighters and emergency re- sponders developed by NIOSHâs National Personal Protective Technology Labora- tory researchers were adopted by the Department of Homeland Security in 2004. The standards were also adopted by the NFPA as private-sector consensus standards (NIOSH, 2007d, p. 154). A major intermediate outcome for subgoal 7.2 has been the contribution of NIOSH project research and TI Research Program anthropometric data to the modification of the Star of Life Ambulance Specification.47 Among the changes called for was the need for increased head clearance above seats based on NIOSH research. The Star of Life Ambulance Specification is a major driver of ambulance design in the United States. Therefore, this modification is likely to have broad impact. The TI Research Programâs work on ambulance safety has also led to continued product development by partners and evaluation of changes to ambu- lance compartments in testing and concept vehicles. For example, the TI Research Program is working with a Florida fire department to evaluate two ambulances with design changes incorporated in the patient compartments based in part on TI Research Program sled and crash test results. American Medical Response and American Emergency Vehicles developed a concept ambulance that has been used as a demonstrator at EMS conferences that includes restraint systems influenced by 45âThe revised standard went into effect on December 20, 2006. In addition to editorial changes, the principal changes to the standard were (1) rewritten design requirements that permit PASS to be other than a âsingle package,â allowing its various components to be located in or combined with other items of protective clothing, and (2) strengthened performance and testing requirements for vibration resistance, impact, water ingress, and alarm signal strength and durability. 46Section 1 of the executive law was amended by adding a new section 159-c-1 (Training; live fire conditions) to read: 1. In the training of fire fighters under live fire conditions no person or persons shall play the role of a victim. 2. For purposes of this section, a live fire condition is any unconfined open flame or device that can propagate fire to a building, a training tower, an acquired structure or other combustible material. 3. A violation of this section shall be punishable by a civil penalty not to exceed one thou- sand dollars paid for by the fire department conducting such training. (NIOSH, 2007f, pp. A44-A45) 47âThe specification revision (KKK 1822 F) was scheduled for full implementation during the third quarter of FY2007.
P r o g r a m m a t ic R e l e v a n c e and I m pac t 91 the TI Research Program and its partners. As an indicator of stakeholder interest, TI Research Program crash test videos have been requested by the International Association of Fire Fighters (IAFF) and other EMS services and fire departments. IAFF incorporated these videos into emergency vehicle operator training for its membership (NIOSH, 2007d, pp. 160-161). Intermediate outcomes for subgoal 7.3 are in relation to the NIOSH-RAND report on disaster safety management. One intermediate outcomeâan American Industrial Hygiene Association 2005 white paper called âIndustrial Hygienistsâ Role and Responsibilities in Emergency Preparedness and Responseâ48âcan be tied directly to recommendations from the NIOSH-RAND report. The reportâs recommendations may have also been an input into information provided in the National Incident Management System (NIMS)49 (released March 2005) and to a task force updating the National Response Plan. With respect to NIMS, the TI Research Program cites the role of the safety officer50 (as described in NIMS) as similar to concerns expressed in the NIOSH-RAND report regarding the need to coordinate activities of organizations and agencies that respond to disasters and terrorist incidents (NIOSH, 2007d, p. 168). A reader survey of user response to and the utility of the NIOSH-RAND report found that many responders (emergency directors and administrators for county and municipal agencies) were using the report to inform planning, change plans, modify training, and implement recom- mendations, among other things (NIOSH, 2007d, p. 168). Discussion The TI Research Programâs work and transfer activities for emergency re- sponders are responsive to program inputs. All subgoals are in line with NORA I. The committee found the FFFIPPâwhich draws on NIOSHâs strengths of case investigations and surveillanceâand the work to develop engineering solutions to problems within ambulance compartments to be particularly strong efforts. Both demonstrate the TI Research Programâs ability to work with partners to identify and address problems through interventions. 48â Available at: http://www.aiha.org/1documents/GovernmentAffairs/EPRWhitePaper_Final.pdf. 49âNIMS is a system mandated by Homeland Security Presidential Directive 5 that provides a consis- tent nationwide approach for governments, the private sector, and non-governmental organizations, to work effectively and efficiently together to prepare for, respond to, and recover from domestic incidents, regardless of cause, size, or complexity (DOT, 2008). 50â According to the NIMS, the safety officerâs responsibilities include âongoing assessment of hazard- ous environments, the coordination of multiagency safety efforts, and implementation of measures to promote emergency responder safety,â and the safety officer âmust also ensure the coordination of safety management and functions and issues across jurisdictions, across functional agencies, and with private-sector and nongovernmental organizationsâ (NIOSH, 2007d, p. 168).
92 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 Although the work facilitating the collection of injury and illness surveillance data on emergency responders and the NIOSH-RAND report on emergency re- sponders are admirable, the committee found subgoal 7.3 to be less coherent. This area may be too large for the TI Research Program, particularly when other agen- cies, such as the Department of Homeland Security, are working on the problem and are likely better resourced for it. There were no end outcomes for the TI Research Programâs work on emer- gency responders. However, there are a few strong intermediate outcomes, such as the influence of FFFIPP investigation reports on revision of the NFPA 1982 PASS standard and Bradleyâs Law. The FFFIPP evaluation study finding that rec- ommendations from firefighter fatality investigations are being used to update safety training programs in thousands of fire departments is important, especially considering the risk-accepting culture of firefighters. With respect to ambulance safety, the influence of NIOSH and TI Research Program research on the Star of Life Ambulance Specifications was an important intermediate outcome. Engineer- ing work in this area also appears to have led to much continued research and development by partners. GOAL 8: REDUCE INJURIES AND FATALITIES TO WORKING YOUTH The TI Research Program developed three subgoals for research aimed at re- ducing injuries and fatalities to working youth: 8.1. Influence legislative changes to protect young workers 8.2. Reduce child agricultural injuries 8.3. Foster the development and widespread use of safety materials and intervention strategies to protect young workers51 Inputs Young workers have received special attention from NIOSH for several im- portant reasons. First, young workers appear to have a higher nonfatal injury rate as compared to all workers, when adjusted for the limited hours they work. This is despite the fact that youth are a protected group and restricted from working in the most dangerous jobs (e.g., driving, construction) and doing the most haz- ardous tasks (e.g., operating heavy equipment). Second, youth have special risk factors, including inexperience on the job, incomplete physical and psychosocial development and, frequently, inadequate training and supervision (especially in 51âSubgoal 8.3 focused on youth workers in nonagricultural settings.
P r o g r a m m a t ic R e l e v a n c e and I m pac t 93 the informal work sector where many youth first enter the workforce). In addition, society recognizes a special duty to protect our youth. Laws that place limits on the types of work youth can do have gone unchanged for decades despite changes in the workplace and what is known about occupa- tional safety and health. In 1998, the IOM report Protecting Youth at Work called upon the Department of Labor to update these laws based on reviews by NIOSH. The focus of subgoal 8.1 is to increase awareness of the need to update these laws (IOM, 1998; NIOSH, 2007k, p. 173). The work was supported by funding from the DOL Employment Standards Administration (ESA) through an interagency agree- ment with the TI Research Program to review the adequacy of existing child labor laws that prohibit youth from work identified as especially hazardous (NIOSH, 2007k, p. 174). Subgoal 8.2 addresses the unique problem of injuries among youth working in agriculture. Between 1992 and 2002, rates of fatalities for youth working in agricultural production were 3.5 times greater than rates for youth working in other industries (NIOSH, 2007k, p. 179). Risk of injury among agricultural workers is higher than for other industries, in general, due to the hazardous nature of the work. In 1996, the National Committee for Childhood Agricultural Injury Preven- tion (of which TI Research Program researchers were members) developed the National Action Plan, which called for NIOSH to serve as the lead federal agency in the prevention of childhood agricultural injury. The initiative was supported by a $5 million congressional appropriation in FY1997. The TI Research Programâs implementation plan for the childhood agricultural injury initiative was based on action steps described in the National Action Plan as well as input from stakehold- ers and peer reviewers (NIOSH, 2007k, p. 180). Subgoal 8.3 was undertaken to increase awareness of safety and health among working youth by developing and implementing effective educational interventions to provide the scientific basis for doing so (NIOSH, 2007k, p. 187). The focus was on reaching all youth, regardless of sector, in order to reduce injuries to youth in their early work lives, and also to invest in the workforce of the future in terms of skills in identifying hazards and preventing injury on the job at any age. In response to comments made in the 1998 NRC report Protecting Youth at Work on the value of fatality investigations for providing the contextual informa- tion missing from surveillance systems, the TI Research Program added youth under age 18 as a target for fatality investigations in 1999. The total intramural and extramural combined funding for the working youth program between FY1997 and FY2005 was $36,013,400 ($14,153,726 intramural and $21,859,674 extramural), making it the largest of the eight goals in terms of funding. At its lowest point in FY1997 the combined funding totaled $1,232,417, and at its peak in FY2001 the funding reached $6,136,918. Funding averaged around $4,000,000 per year. FTEs ranged from a low of 7.7 in FY2005 to a high
94 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 of 13.3 in FY1999. Most of the funding appears to come from the congressional appropriation of $5,000,000 for child agricultural injury reduction (see Table 1-2). Although the funds do not seem adequate at first glance, it does appear that the available funds have been used effectively, particularly in forming state and local cooperative agreements. Activities Since FACE Programâs targeting of young worker deaths in 1999, the TI Re- search Program has conducted 29 FACE investigations of such worker deaths. An additional 42 fatality investigations have been conducted by states with cooperative agreements with the TI Research Program. The committee supports the addition of young worker deaths as a target for the FACE Program, because these investiga- tions provide insight into the circumstances leading to injuries and the necessary intervention strategies. FACE reports may also provide specific guidance in pre- venting particular types of fatal injuries. In addition, this activity was relevant to subgoal 8.1, because the investigations often found that youth have been injured while performing tasks not prohibited by child labor laws (NIOSH, 2007k, p. 174). In the evidence package, the TI Research Program notes that it is considering scal- ing back or removing young worker deaths as a FACE Program target, because the investigations often do not identify new strategies for the prevention of young worker injuries (NIOSH, 2007k, p. 176). While scaling back may be warranted, the committee supports continuation of the young worker fatality investigations to respond to changing risk factors. For subgoal 8.1, the TI Research Program has devoted substantial effort to drawing together existing research results so that they are useful to agencies or legislators considering the development of new rules or laws affecting the safety of young workers. For example, in the interagency agreement with ESA, the TI Research Program performed a review of existing child labor laws that prohibit youth from performing work identified as especially hazardous.52 The agreement also led to the development of requests for application (RFAs) for extramural re- search on youth working in construction. A separate RFA for research on childhood agricultural injury resulted in 24 grants for study of the incidence of and risk for childhood agricultural injury (NIOSH, 2007k, p. 174). While recognizing the importance of child labor laws in protecting young workers, the committee had some reservations about the TI Research Programâs emphasis on laws that call for the removal of youth from high-risk jobs rather than 52âSeeMiller, M. E., and D. Bush. 2004. Review of the federal child labor regulations: Updating hazardous and prohibited occupations. American Journal of Industrial Medicine 45:218-221.
P r o g r a m m a t ic R e l e v a n c e and I m pac t 95 the control of hazards. Although effectively enforced child labor laws can protect working youth, adult workers in these same jobs may continue to be at risk. The committee underscores the continuing need for research to identify and control hazards in jobs commonly held by youth. Many of these same jobs are often held by immigrant and minority workers, who may also be considered vulnerable. Ef- forts to control hazards driven by concern for youth can result in the protection of all workers. For subgoal 8.2, it should be noted that most activities under the working youth goal are in the area of agricultural injuries. This is not surprising consider- ing Congress has appropriated several million dollars annually for this research since FY1997. This is an important area, because youth injury rates in agriculture are very high. Despite the small proportion of youth working in agriculture, the agriculture, forestry, and fishing sector accounted for more than 40 percent of all young worker deaths between 1998 and 2002 (NIOSH, 2007k, p. 179). Because of limitations in the BLS Annual Survey of Injuries and Illnesses, the committee can- not make a reliable parallel comparison for nonfatal injuries. Approximately 25 percent of the congressional appropriation for agricultural injury has been used for surveillance and coordination efforts, and about 75 percent has been used for extramural research and outreach (NIOSH, 2007k, p. 180). Sev- eral new surveillance activities were designed to provide an ongoing picture of the incidence of these injuries. Using ongoing survey relationships of NASS, NIOSH has collected information from farm operators about agricultural injuries to chil- dren in 1998, 2001, and 2004 (in the CAIS). A parallel survey of minority farms, the M-CAIS, was conducted in 2000 and 2003. In addition, the TI Research Program developed a farm worker injury model to supplement data already collected from farm workers by the DOL in the NAWS. This survey includes young workers, so it provides information about their injuries. NIOSH has also supported several ex- tramural surveillance activities in this area. These include a project that ascertained the number of agricultural injuries incurred by ninth to twelfth graders seen in Minnesota emergency departments. The TI Research Program developed RFAs that resulted in cooperative agreements to fund the National Childrenâs Center for Rural and Agricultural Health and Safety (NCCRAHS) and in 50 research grants (since 1997) to characterize young worker agricultural injuries, risk factors, and outcomes for young agricultural workers and to develop and evaluate interventions. Since the initiation of the youth FACE investigation program in 1999, the TI Research Program has conducted 3 investigations of young worker deaths in agriculture while the state-based program has conducted 17 such investigations. Findings helped to identify risk factors for fatalities, such as inadequate training and supervision, mismatch between equipment and physical characteristics of youth, use of equipment without safety features, and work assignments prohibited
96 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 by child labor laws (NIOSH, 2007k, p. 181). As discussed for subgoal 8.1, the TI Research Program led a review of the adequacy of existing child labor laws, some of which are applicable to agricultural work. Activities for subgoal 8.3 centered on the creation of model approaches and educational materials to provide health and safety training to youth, often through high schools. The TI Research Program developed RFAs for community-based demonstration projects to develop and test approaches and materials that resulted in community-based projects in several regions and states. Through these dem- onstration projects, many educational materials and dissemination methods were tested and promising approaches were identified and documented, including the development of state teams that bring government agencies and other stakeholders together to coordinate efforts to protect young workers. The TI Research Programâs work in this area also involved the establishment of relationships with partners in the public and private sectors for input on the programâs products and collabora- tion in outreach efforts. Transfer Activities Youth fatality investigations of both agricultural and nonagricultural injuries conducted by the TI Research Program are posted on the NIOSH Web site and were provided to ESA and OSHA. State-based FACE programs disseminate reports within their states (NIOSH, 2007k, p. 175). The TI Research Program has devoted considerable time and effort to transfer activities related to subgoal 8.1. The program developed guidelines for the conduct of investigations of young worker deaths and provided technical assistance to states participating in state-based FACE programs. The TI Research Program played an important role in providing statistics and analyses to ESA, which is responsible for developing child labor regulations and developing and enforcing federal child labor laws. In particular, the TI Research Program has provided recommendations for revisions in federal child labor laws based on analyses of existing data and research, some of which were funded by NIOSH. New child labor regulations, based in part on NIOSH input, became effective in 2005 (see âOutcomes,â below). The TI Re- search Program provided technical assistance to state-based young worker injury and illness surveillance systems in Massachusetts and Wisconsin. The TI Research Program also cosponsored the study on the health and safety implications of child labor that led to the IOM (1998) report Protecting Youth at Work (NIOSH, 2007k, pp. 173-175). For subgoal 8.2, the TI Research Program has engaged in transfer activities to facilitate information sharing relevant to reducing injuries of young workers in
P r o g r a m m a t ic R e l e v a n c e and I m pac t 97 agriculture. The TI Research Program helped to plan and participated in a 2001 Summit on Childhood Agricultural Injury Prevention that assessed the progress and update of the 1996 National Action Plan. Between 1999 and 2004, the TI Research Program convened an annual meeting of researchers with NIOSH funding through NCCRAHS to share findings and discuss research problems and solutions. The TI Research Program also formed and chairs the federal IAWG on Preventing Child- hood Agricultural Injuries. The working group is a forum for those with a stake in childhood agricultural injury prevention to discuss the state of the research and the incorporation of findings into safety products (NIOSH, 2007k, p. 181). The TI Re- search Program has also been engaged with many organizationsâboth government and privateâto disseminate information about risks to young agricultural workers and how to prevent these risks. The TI Research Program worked with NASS to provide farm safety materials focusing on youth to the approximately 100,000 farm operators that it surveys (NIOSH, 2007k, p. 182). Finally, as stated for subgoal 8.1, the TI Research Program provided recommendations to ESA for revisions to federal child labor laws by submitting comments to an Advanced Notice for Proposed Rule- making. These comments included a recommendation for increasing the minimum age for hazardous agricultural work from 16 to 18 and the removal of the family farm exemption. The 2002 NIOSH report recommended revisions to 8 or 11 HOs in agriculture and a new HO for both agricultural and nonagricultural industries prohibiting youth from work that requires respirators (NIOSH, 2007k, p. 183). Transfer activities for subgoal 8.3 included a provision of technical assistance to the community-based demonstration project grantees in the execution of proj- ects and a modification of materials developed by these programs for national use (NIOSH, 2007k, p. 187). Thousands of copies of NIOSH publications on young worker safety were disseminated through targeted mailings. Outputs The working youth program has produced a number of tangible, relevant, and helpful outputs. For example, for subgoal 8.1, NIOSH not only used existing surveillance data but also developed new surveillance sources, both by building on existing surveys conducted by other agencies and by funding new surveillance activities. These include new state-based surveillance activities in Wisconsin and Massachusetts focused on working youth. They also include sector-based surveil- lance in agriculture and construction. This expanded surveillance is paving the way for a more comprehensive understanding of the hazards facing working youth. These outputs will enable NIOSH to better plan new research focused on working youth and to better evaluate the impact of ongoing activities.
98 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 Specifically for subgoal 8.1, the TI Research Program has written 15 peer- reviewed articles since 1996, which have largely been concerned with establish- ing the magnitude and patterns of young worker injuries and fatalities. External collaborators have generated 25 articles in addition to this. The TI Research Pro- gram authored 11 NIOSH documents with data on young worker injuries and completed 29 FACE reports of investigations of youth fatalities, while states with cooperative agreements completed another 42 investigation reports. Findings from the investigations helped to show that work tasks not prohibited by existing child labor laws have resulted in fatal injuries. NIOSH has also been actively working with collaborators to produce recommendations concerning 34 HOs. Finally, the TI Research Programâs contribution to young worker initiatives in Massachusetts and California has led to a broadening effect involving collaborations with mul- tiple other agencies. This appears to be a highly successful model of transfer that has been replicated now by multiple states with the support of the National Young Workers Resource Center (operated jointly by the California and Massachusetts programs and funded by OSHA). For subgoal 8.2, the TI Research Program has published 23 articles in the peer-reviewed literature as well as 31 articles by external researchers. These articles describe the magnitude and patterns of injuries among young agricultural workers and make recommendations for prevention. In addition, nine NIOSH and three USDA documents have been generated (NIOSH, 2007k, p. 183). There have also been 3 fatality investigation reports completed by the TI Research Program involv- ing young worker deaths in agriculture, as well as 17 fatality investigation reports completed by states. In 1997, the TI Research Program formed the federal IAWG on Preventing Childhood Agricultural Injuries. The TI Research Program chairs the working group, which meets biannually, and provides a forum for discussion of ongoing activities and the incorporation of new findings into safety products (NIOSH, 2007k, p. 181). The TI Research Program provided recommendations to ESA for revisions to federal child labor laws by submitting comments to an Ad- vanced Notice for Proposed Rulemaking and in the 2002 NIOSH report, several of which applied to youth working in agriculture. The TI Research Program has published 10 peer-reviewed articles since 1996 supplemented by another 23 articles from external researchers for work related to subgoal 8.3. Thirteen NIOSH documents have also been generated. Material has also been generated to engage young workers directly, including stand-alone cur- ricula and curricular activities for integration into current high school programs. NIOSH, in collaboration with the University of California at Berkeley program, has now developed curricula tailored for each of the 50 states and posted them on its Web site, making it easy for educators to access and use these educational approaches.
P r o g r a m m a t ic R e l e v a n c e and I m pac t 99 Outcomes An intermediate outcome cited for subgoal 8.1 was changes to FLSA child labor laws that went into effect February 14, 2005.53 Because research and recommenda- tions from the TI Research Program were cited among justifications for the changes in the final rule,54 the committee agrees that the TI Research Programâs work had some role in shaping the changes to the child labor laws. Another intermediate outcome was broad stakeholder use of the 2002 report âNational Institute for Oc- cupation Safety and Health (NIOSH) Recommendations to the U.S. Department of Labor for Changes to Hazardous Orders,â55 which echoed the comments submitted by NIOSH to the DOL in the rule-making comment period. In addition to the DOL, the report has been used by others looking to improve workplace safety for youth. In 2003, a California congressman used the report as the basis for a section of a proposed Youth Worker Protection Act (H.R. 2870, 109th Congress) on hazardous occupations for youth, although the legislation was not passed. The Child Labor Coalition referenced the report in a 2006 letter to the Secretary of Labor requesting action on child agricultural labor regulations and in a document questioning U.S. compliance with International Labor Convention 182, which calls for prohibition and elimination of certain forms of child labor. Another intermediate outcome for subgoal 8.1 was the contribution of a youth FACE investigation conducted in Oregon to a 2005 child labor law in that state prohibiting youth under age 18 from working in occupations involving the use of explosives (NIOSH, 2007k, pp. 175-176). A NIOSH-funded project in Massachusettsâthe Teens at Work Injury Surveillance and Prevention Projectâwas instrumental in providing data that contributed to a revision of the Massachusetts child labor laws as well as changes in policy and training in vocational education schools. The TI Research Program cites the use of surveillance data on youth working in agriculture performed by other parties both in government and in the private sector to guide prevention efforts as an intermediate outcome for subgoal 8.2. A particularly strong indication of stakeholder interest was the use of TI Research 53âChanges were for youth workers and (1) cooking and cooking-related duties, (2) all work on or about roofs, (3) loading of power-driven balers and compactors, and (4) teen driving on the job. A complete description of changes can be found in the final rule at http://www.dol.gov/esa/regs/ fedreg/final/2004027182.htm. 54âThe final rule states that NIOSH provided the DOL with epidemiological data on a number of issues related to regulations for youth workers aged 14 and 15 and occupations covered by HOs during the rule-making comment period. NIOSH also provided the DOL with statistics regarding occupational injuries and made several recommendations (Federal Register 69(241):75381 (2004)). 55âDocument can be found at: http://www.cdc.gov/niosh/docs/NIOSHRecsDOLHaz/pdfs/ DOL-recomm.pdf.
100 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 Program statistics on injuries among youth working on farms in the proposed Childrenâs Act for Responsible Employment (CARE) of 200556 (CARE Act, H.R. 3482). This act proposed changes to child labor laws in agriculture and identified the TI Research Program youth farm injury data as a source of data for an an- nual report on injuries to youth working on farms in the United States. The 2002 NIOSH report that provided recommendations to ESA on changes to child labor laws has been used by others advocating for changes in child labor regulations in the agriculture industry (NIOSH, 2007k, p. 183). The TI Research Program also notes an end outcome for subgoal 8.2ânamely, a decline in the number of injuries and the rates of nonfatal injuries among agri- cultural workers under age 18 between 1998 and 2004. The number of work-related injuries decreased 50 percent over this period (from 11,970 in 1998 to 5,740 in 2004), and the rates of nonfatal, work-related injuries decreased 30 percent (from 10.5 per 1,000 working youths in 1998 to 7.3 per 1,000 working youths in 2004; NIOSH, 2007k, p. 184).57 The committee believes that the contributions of the TI Research Program, in particular through outreach activities done in collaboration with partners, likely played some role. As an intermediate outcome for subgoal 8.3, young worker safety efforts have continued for several state-based teams. Work of investigators with community- based demonstration projects in Oakland, California, and the Northeast Young Worker Resource Center has been extended through funding from OSHA (NIOSH, 2007k, p. 189). The Teens at Work surveillance project in Massachusetts resulted in a technological intervention. The project identified hot coffee and slurry from cof- fee brew baskets as a common source of occupational injury among Massachusetts teens. In response to the finding, the corporate headquarters of a national bakery chain in 2001 began to require that store owners purchasing new equipment in- stall brew baskets and shields to prevent spillage. A retrofit kit was designed and made available to store owners who are not purchasing new equipment (NIOSH, 2007k, p. 189). Stakeholder interest in the TI Research Programâs work in this area has been evidenced by requests for additional copies of TI Research Program- d Â eveloped young worker safety and health materials; incorporation of materials into school-based occupational safety and health classes; and citation of TI Re- search Program statistics, findings, and prevention recommendations by the press and in safety programs (NIOSH, 2007k, p. 190). 56âTheact was submitted in the House of Representatives in July 2005, but never passed. 57âThediscrepancy between the rate and the absolute number derives from decreasing numbers of youth working in agriculture.
P r o g r a m m a t ic R e l e v a n c e and I m pac t 101 Discussion The TI Research Programâs activities for young workers have demonstrated the significance of innovative, as well as continuing, surveillance activities. The value of such surveillance data to focused approaches cannot be overemphasized in terms of the benefits likely to accrue. In other areas of research activity, however, it is clear that many activities are better described as research to practice (r2p). While the committee endorses the TI Research Programâs efforts to work with various constituencies to implement products and programs, it appears that there is a significant danger that actual research into the causes of traumatic injury is underemphasized relative to implementation. The choice to add youth to the FACE Program in 1999 was a good one, and the committee supports continuation of a scaled-down youth FACE Program in the future if new interventions are no longer being identified. The young worker activity also focused on the development of legislative ap- proaches to reducing injuries. The moderate nature of its success apparently arises from a significant lack of interest and âpickupâ by the various bodies responsible for promulgation and, perhaps more importantly, enforcement. The ancillary activity of partnering with groups representing the constituency at risk, however, appears to have been much more successful and demonstrated a âpullâ for these activities, be they r2p or research, rather than the âpushâ that NIOSH is (appropriately) try- ing to avoid. Activities resulted in a number of relevant outputs. Particularly strong was the development of new surveillance sources that add to the knowledge base of risk factors for occupational injury among youth. More comprehensive data will help NIOSH and the TI Research Program in the evaluation of existing efforts as well as the targeting of future efforts toward youth. A number of products developed and tested through the demonstration projects seem to have been well received by stakeholders, as evidenced by requests for additional copies and incorporation of products into youth occupational safety programs. Finally, the TI Research Programâs goal on working youth appears to have resulted in several modest yet important intermediate outcomes. Outputs, such as surveillance data and the 2002 NIOSH report âNational Institute for Occupation Safety and Health (NIOSH) Recommendations to the U.S. Department of Labor for Changes to Hazardous Ordersâ58 summarizing recommendations for updating child labor laws, have continued to be used by groups both in the government and in the private sector. Through outreach activities with partners, the TI Research Program in all probability had some part in the end outcome for subgoal 8.2, 58âDocument can be found at: http://www.cdc.gov/niosh/docs/NIOSHRecsDOLHaz/pdfs/ DOL-recomm.pdf.
102 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 namely a decline in injuries among young agricultural workers between 1998 and 2004. EVALUATION OF RELEVANCE The guidance for assessing relevance in the Framework Document is âwhether the program appropriately sets priorities among research needsâ and âhow engaged the program is in appropriate transfer activitiesâ (see Appendix A, p. 137). A rel- evance score of 5 signifies a conclusion that the research is in high-priority areas and the program is significantly engaged in transfer activities, whereas a score of 4 signifies that the research is in priority subject areas and the program is engaged in appropriate transfer activities (see Box 2-1). The committee reviewed the work supporting the 8 specific goals (including 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 attention driven by congressional directive (e.g., the AFS). Three goals represent specific worker populations identified by location (Alaska), age (youth), or sector (emergency response). NIOSH has clearly driven a national sensitivity to some specific safety problems. For example, the committee concludes that NIOSH attention to workplace violence has shined a light on a previously neglected area. The committee concludes that for the most part, the goals are appropriate and relevant to the burden of traumatic injury in the workplace. The burden of injury Box 2-1 Scoring Criteria for Relevance 5â = 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. 4â = Research is in priority subject areas and NIOSH is engaged in appropriate transfer activities for completed research projects or reported research results. 3â = 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. 2â = Research program is focused on lesser priorities and NIOSH is not engaged in or plan- ning some appropriate transfer activities. 1â = Research program is not focused on priorities and NIOSH is not engaged in transfer activities.
P r o g r a m m a t ic R e l e v a n c e and I m pac t 103 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 work sites in the country as part of its review. Rather, the committee understands the challenges NIOSH faces in prioritizing research with such restricted resources and concludes that given this limited budget and based on committee membersâ expert judgment, the TI Research Program has made overall appropriate selections of general areas to pursue. While the committee concluded that many of the goal areas were high priorityâ such as Alaska and falls from elevationsâit identified gaps, such as falls from same elevation, several sectors within workplace violence, and a narrow focus within machines. There were also areas in which TI Research Program research was âstuckâ in its approach (e.g., a focus on engineering solutions to tractor rollovers, instead of a switch to policy research to accomplish transfer to the field). As described in previous sections of this chapter, the TI Research Program engages in appropriate transfer activity within some, but not all, of the goal areas. TI Research Program staff has participated in the ANSI Z15 committee (subgoal 1.1), an important collaborative transfer activity. The transfer activities in goal 2, if successful, are likely to lead to the introduction of TI Research Program- dependent safety innovations, primarily engineering-based, but also developed from FACE investigations. TI Research Program staff has urged ASABE to develop a performance standard for the AutoROPS (subgoal 4.1), it has contributed to a DOL-OSHA committee that resulted in OSHA guidelines for nursing homes (subgoal 5.1), it has engaged in significant transfer activities related to legislative changes to protect young workers (subgoal 8.1), and it has provided recommen- dations for revisions in federal child labor laws (which became effective in 2005). The TI Research Program-funded Youth at Work program was instrumental in the passage of revised child labor laws in Massachusetts. These transfer activities are appropriate and related to the intermediate outcomes demonstrated for some of the program activities. Score for Relevance 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. This score is based on the fact that research is mostly in priority and some high-priority subject areas and has a range of involvement in transfer activities.
104 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 2-2 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. EVALUATION OF IMPACT The directions for assessing impact on end outcomes or well-accepted interme- diate outcomes in the framework seem to hinge on a distinction between âmajor contributionsâ for a score of 5 and âsome contributionsâ for a score of 4 (see Box 2-2). The committee understands that a determination of major contributions does not âimply that the NIOSH program was solely responsible for observed improve- ments in worker health and safetyâ; the committee is aware of the challenges in assigning such responsibility and has not attempted to do so. Intermediate Outcomes The Framework Document describes intermediate outcomes as âimportant indicators of stakeholder response to NIOSH outputs. They reflect the impact of program activities and may lead to the desired end outcome of improved work- place safety and health.â Intermediate outcomes fall into the major categories of public policy impact, training and education, and self-reported use or repackaging of NIOSH material by stakeholders. The committee found evidence of effects on well-established intermediate outcomes in all of the eight goal areas and in all types of outcomes. These have been documented for each goal and subgoal in previous sections of this chapter. This section briefly summarizes some exemplars by the type of intermediate outcome rather than by goal.
P r o g r a m m a t ic R e l e v a n c e and I m pac t 105 Intermediate outcomes related to public policy impact refer to the production (by those outside NIOSH) of guidelines or regulations based wholly or partly on NIOSH research. The TI Research Program has been associated with the develop- ment of both voluntary guidelines and regulations in several areas (goal 1: motor vehicles; goal 2: falls from elevations; goal 3: workplace violence; goal 4: machines; goal 5: back injuries; goal 6: Alaska; and goal 8: working youth). Approval of the ANSI Z15.1 standard, Safe Practices for Motor Vehicle Opera- tions, is a success for goal 1. This filled the gap left by the Federal Motor Carrier Safety Regulations, which apply only to commercial drivers. The ANSI standard will help protect all employees who operate a motor vehicle as part of their job. Another very important intermediate outcome was the incorporation of a NIOSH recommendation related to HO No. 2 (motor vehicle occupations) into a final rule published by the DOL in 2004. The DOL published a final rule59 on the HO prohibiting all workplace driving on public roadways by 16-year-old workers and placed restrictions on driving by 17-year-old workers. The TI Research Programâs work on falls from telecommunications towers supported the development of two important policy documentsânamely, the first statewide telecommunications tower standard (in North Carolina), which addresses safety procedures to be used during tower construction and maintenance, and the OSHA Telecommunications Tower Task Force Compliance Directives, which ad- dress inspection procedures. OSHA published recommendations for workplace violence prevention programs in 1998 and guidance documents for preventing workplace violence to healthcare and community service workers in 2004. Notable intermediate outcomes in goal 4 (machines) are the revisions to ANSI Z245.5 Stan- dards Committee to require a security switch. This will serve to protect workers at municipal and commercial recycling centers. An amendment to the FLSA restricts workers under the age of 18 years from loading balers that do not meet the ANSI standard and prohibits them from operating balers (HO No. 12).60 The research in patient handling has been cited as an important source of evidence leading to the passage of safe patient handling legislation in several states (Texas, Washington, Rhode Island, Ohio, Hawaii, and New York). As discussed above, BLS data indicate a decrease in rates of injuries likely related to patient handling from the early 1990s to the present. Other changes in public policy related to TI Research Program findings are the USCG Dockside Pre-season Boarding 59âRegulationsimplementing the act permit the Secretary of Labor to prohibit the employment of youth in occupations declared âparticularly hazardous for the employment of children . . . or detri- mental to their health or well-beingâ (29 USC 201 Sec. 3(1)). These prohibited activities are referred to as Hazardous Occupations Orders (HOs). The minimum age, by statute, for HOs in nonagricul- tural occupations is 18; the minimum age in agricultural occupations is 16. 60âHO No. 12 (balers), 29 CFR Part 570.63.
106 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 Program and the helicopter safety guidelines related to goal 6, and changes in the FLSA in 2005 related to goal 8. Intermediate outcomes related to training and education refer to programs sponsored by other organizations. These have been documented in previous sec- tions of this chapter and are summarized only briefly here. The NIOSH document âBuilding Safer Highways and Work Zonesâ61 has been used in an OSHA training course and by other organizations for safety training. TI Research Program work on falls from telecommunications towers supported the development of OSHA train-the-trainer programs as well as comprehensive NATE manuals. TI Research Program staff and their research related to workplace violence have influenced OSHA recommendations and guidelines as well as guides on workplace violence prevention by the Office of Personnel Management and the American Society for Industrial Security. TI Research Program findings on safe patient handling have been used in professional organization training programs and textbooks. Work in Alaska aviation has been used extensively in FAA training programs, including public service announcements and training videos Another category of intermediate outcome is self-reported use and/or repack- aging by stakeholders. Many NIOSH reports have been picked up by stakeholders and disseminated. For example, the TI Research Program-authored report âBuild- ing Safer Highway Work Zones: Measures to Prevent Worker Injuries from Vehicles and Equipmentâ62 has been distributed by OSHA offices and reproduced as part of the Laborersâ Health and Safety Fund of North America 2003. The blind area equipment reports have been requested by several stakeholders. The committee includes in this category stakeholder-initiated changes in safety technology and workplace environments.63 The FACE Program can be particularly useful in illuminating these kinds of risks. A FACE investigation of a scalping accident and the subsequent identification of other cases led to a retrofit by the manufacturer of the hay baler involved in all five cases. The manufacture of sealed agricultural plow frames revised its manufacturing process to avoid the scrap metal that appeared to be responsible for ignition hazards identified in FACE investiga- tions. Although the original ROPS work occurred outside the period of committee evaluation, manufacturers have changed the design of tractors (although uptake of the technology is quite slow). Equally important to the research that led to improvements in equipment design is research showing that a technology is not effective. The research on back 61âNIOSH. 2001. Building safer highway work zones: Measures to prevent worker injuries from vehicles and equipment. HHS (NIOSH) Publication No. 2001-128. 62âSee footnote 61 for reference. 63âThis is distinct from public policy impact, which would force stakeholders to make changes.
P r o g r a m m a t ic R e l e v a n c e and I m pac t 107 belt use for materials handling demonstrated no effect on injuries, and two major retail chains no longer provide or require back belt use. Research demonstrating no effect of an intervention is as important as research that does show an effect, because discontinuance of an ineffective intervention allows more promising in- terventions to be studied and introduced, which might not have occurred had the workers and their management assumed the technology to be effective. Other safety technology introductions based on the research of the TI Research Program, although limited, include those involving patient compartments, such as the Star of Life Ambulance Specifications, changes in the patient compartment in some ambulances in Florida, and restraint systems for a concept ambulance. End Outcomes NIOSH reports improvements in end outcomes for five of the eight goals: workplace violence (a very modest decrease in fatalities compared to societal ho- micides), machines, acute back injury in patient handling, high-risk occupations in Alaska, and nonfatal agricultural work-related injuries in youth (but not non- agricultural work-related injuries in youth). As noted in this list, the committee greets with some reservation the reports of an impact on workplace violence fatalities given that societal homicides decreased similarly over the same period of time and these trends likely are inextricably linked. The committee discusses important contributions to intermediate out- comes in a previous section. NIOSH reports a steady decrease in fatalities caused by machines, plant and in- dustrial powered vehicles, and tractors since 1992. The number of deaths decreased 16 percent and the fatality rates declined 30 percent. The committee agrees with the NIOSH conclusion that it is difficult to quantify the contributions of the TI Research Program to these decreases. The probable source of improvement in end outcomes related to goal 4 (machines) is primarily due to the FACE investigations (subgoal 4.3), not the other recent efforts on ROPS or the limited work on paper balers. The committee is supportive of the FACE Program and recognizes its con- tributions. It raises this merely to make the point that the end outcomes related to the machines program derive from one program and not from other interventions supported in subgoals 4.1 and 4.2. There is little doubt that the successes in the Alaska program are numerous and important. The program benefited from a dedicated source of funding (a congres- sional directive), a reasonably narrow focus, and locus as a state-based program. Having TI Research Program staff in close physical proximity to the many impor- tant stakeholders was likely influential in the success of the program. This is not a feasible strategy in most areas of TI Research Program work, however. As an aside,
108 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 committee hopes that the TI Research Program can extend the AFS successes in Alaska and across the country. The combination of important partnerships, focus, sufficient resources, and a state-based program with specific attention to the public health model could be applied to other high-risk industries in Alaska as well as similar high-risk industries in other parts of the country. The AFS model can serve as a model of success for the program as a whole. Surveys from farm operators suggest a marked decrease in nonfatal work- r Â elated injuries among youth between 1998 and 2004. There is not, however, evi- dence of decreased injuries of working youth in other sectors. The committee views the changes in end outcomes with some reservations, un- sure of the TI Research Program contributions to the results. However, the commit- tee favorably views any progress in reducing occupational traumatic injuries and is confident of some degree of NIOSH contributions. Given the very limited resources under which the TI Research Program operates, results regarding end outcomes are admirable. Other important external factors that likely restrain success include OSHA inaction, the difficult nature of some of the industries in which injuries are high (e.g., the culture of individualism and risk acceptance in the agricultural and logging industries), and the difficulties of getting small- to medium-sized en- terprises to invest in safety technologies. The TI Research Program might benefit from efforts to increase its capacity and expertise in policy research, in behavioral and social science research, and in directed efforts to understand how to impact small- to medium-sized enterprises. Chapters 3 and 4 address these issues. Score for Impact The committee commends the TI Research Program for its contributions toward reducing occupational traumatic injuries. As documented in the previous section, the TI Research Program is associated with impact on either intermediate or end outcomes in each major goal. The committee recognizes that external fac- tors, specifically severely limited resources and inaction on the part of OSHA, can be significant barriers to the TI Research Programâs 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 in 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.
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