4
Recommendations for Program Improvement

As the only federal research program focused specifically on the challenge of preventing occupational hearing loss, the Hearing Loss Research Program within the National Institute for Occupational Safety and Health (NIOSH) should be an undisputed leader and source of expertise in the fields of occupational hearing loss research, including hearing loss prevention programs, hearing protection, noise control engineering for occupational hearing loss prevention, and occupational hearing loss surveillance and risk factors. From its evaluation of the relevance and impact of this NIOSH program (Chapter 2) and its assessment of the identification of new research areas (Chapter 3), the Committee to Review the NIOSH Hearing Loss Research Program identified several potential opportunities to improve the relevance of the program’s work and strengthen its impact on reducing occupational hearing loss. This chapter provides the committee’s recommendations for improvement of the Hearing Loss Research Program. The committee recognizes that some of these recommendations carry resource implications that have not been fully explored here. It hopes that NIOSH will place a high enough value on the Hearing Loss Research Program to give serious consideration to finding ways to respond to these opportunities for improvement.

PROGRAM MANAGEMENT IN A MATRIX ENVIRONMENT

The NIOSH Hearing Loss Research Program operates in a matrix environment, as do many other NIOSH research programs. This approach to program



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Hearing Loss Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health 4 Recommendations for Program Improvement As the only federal research program focused specifically on the challenge of preventing occupational hearing loss, the Hearing Loss Research Program within the National Institute for Occupational Safety and Health (NIOSH) should be an undisputed leader and source of expertise in the fields of occupational hearing loss research, including hearing loss prevention programs, hearing protection, noise control engineering for occupational hearing loss prevention, and occupational hearing loss surveillance and risk factors. From its evaluation of the relevance and impact of this NIOSH program (Chapter 2) and its assessment of the identification of new research areas (Chapter 3), the Committee to Review the NIOSH Hearing Loss Research Program identified several potential opportunities to improve the relevance of the program’s work and strengthen its impact on reducing occupational hearing loss. This chapter provides the committee’s recommendations for improvement of the Hearing Loss Research Program. The committee recognizes that some of these recommendations carry resource implications that have not been fully explored here. It hopes that NIOSH will place a high enough value on the Hearing Loss Research Program to give serious consideration to finding ways to respond to these opportunities for improvement. PROGRAM MANAGEMENT IN A MATRIX ENVIRONMENT The NIOSH Hearing Loss Research Program operates in a matrix environment, as do many other NIOSH research programs. This approach to program

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Hearing Loss Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health management offers benefits to the organization as a whole, but it poses challenges for the Hearing Loss Research Program’s ability to develop and implement a program plan and to allocate resources among the varied research needs related to occupational hearing loss prevention. The committee notes that even the most talented leadership will find it difficult to successfully manage a program distributed across separate organizational units and to catalyze the planning and mobilization of resources necessary for a cohesive program. The small size of the program also demands skill in setting priorities for program activities and allocation of program resources. The program as a whole requires leadership specifically dedicated to championing a better Hearing Loss Research Program, as do each of the program areas represented by the four research goals. In addition to having excellent management skills, leaders should be well-regarded experts in hearing loss prevention, noise control engineering, or surveillance methods. They should be involved with other organizations through activities such as participation in standards committees, advisory panels, and boards. The program’s leaders should also bring experience in implementing hearing loss prevention or noise control engineering practices in the field. Since 1996, the Hearing Loss Research Program has had to respond to significant organizational and leadership challenges. The incorporation of activities at the Pittsburgh Research Laboratory added a new and physically separated component to the program. The Hearing Loss Research Program also lost two experienced and recognized leaders in the field. Furthermore, the Hearing Loss Research Program has had to respond to the NIOSH-wide effort to look toward a second decade of the National Occupational Research Agenda (NORA) and the demands of preparing for the review by this committee. Although the Hearing Loss Research Program has persevered admirably during these transitional times, the committee sees a need to foster leadership that can provide coherence to the program, increase collaboration, and serve as an effective advocate within the matrix environment in which it operates. The committee is encouraged to see that NIOSH has recently appointed from within the NIOSH management staff an overall program manager who is expected to monitor the program’s activities and resources. In this role, the program manager will have an advisory and consultative relationship with the organizational units in which the Hearing Loss Research Program’s work is done, but he will not have authority to mandate the allocation of resources to the program as a whole or its components. The program manager did not make a formal presentation to the committee, and even though he is new to this position, it would have been valuable to the committee to hear his views on the program and the Institute of Medicine review.

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Hearing Loss Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health Foster effective leadership. NIOSH should ensure that the Hearing Loss Research Program and its components have leadership with appropriate technical expertise as well as skills in managing in a complex environment, mobilizing resources, promoting collaboration within the program, and increasing program coherence. All of these leaders must serve as champions of the program within and outside NIOSH and help to garner adequate resources and recruit expertise. The leaders should be respected and involved in the hearing loss prevention community and in their own fields of expertise. NIOSH should provide the overall program leader with sufficient authority to make appropriate program and budgetary decisions. It bears repeating that the leaders of the Hearing Loss Research Program must contend with a small budget—about $7.5 million in fiscal year (FY) 2005—much of which is reserved for work related to mining or for extramural research. The committee urges NIOSH to consider the need for program resources that are commensurate with a more robust pursuit of the program’s goals and with sustaining the continuity of the most relevant research in specific program areas. ACCESS TO INTRAMURAL AND EXTRAMURAL EXPERTISE As described in Chapters 2 and 3, the committee is concerned that the Hearing Loss Research Program has lacked adequate internal technical expertise, especially in the specialized areas of epidemiology and noise control engineering, and has appeared to rely on a fairly narrow group of external experts for input and collaboration. For the program to hold the position of national leadership in occupational hearing loss prevention and noise control research, it must draw on outstanding members of the communities responsible for the prevention of occupational hearing loss (as detailed in Chapter 1) both within and outside the program. The committee commends the efforts by the management of the Hearing Loss Research Program to increase capabilities of its staff by supporting graduate education in fields such as noise control engineering. Although this approach can supplement the program’s resources, it is not a substitute for the recruitment of senior-level researchers with demonstrated expertise in areas essential to the effective performance of the program. Similarly, seeking contributions to program planning discussions from outside experts is appropriate, but relying on a small set of contributors (e.g., only six outside participants at the Futures Workshop) does not provide sufficient breadth and depth of expertise.

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Hearing Loss Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health As the Hearing Loss Research Program garners additional internal expertise, it should also broaden and strengthen its ties to sources of external scientific, hearing loss prevention, and noise control engineering expertise, such as other federal agencies, industry, and the military. With additional expertise, the program will be better positioned to have an impact on occupational hearing loss through its current portfolio as well as to move into emerging research areas for the future. Recruit additional expert researchers to the NIOSH Hearing Loss Research Program staff. The Hearing Loss Research Program should recruit and retain experienced professionals with recognized expertise in the fields of epidemiology and noise control engineering who can exercise leadership in planning, conducting, and evaluating the program’s work in these crucial areas. It is essential for the program to make gaining this additional expertise a priority. Expand access to outside expertise. The program should make efforts to draw upon a wider representation of the communities responsible for the prevention of occupational hearing loss as reviewers, conference participants, and collaborators. As part of this effort, the program should strengthen ties to the National Institute on Deafness and Other Communication Disorders and other components of the National Institutes of Health to benefit from additional interactions with the scientific researchers there. The program should also explore collaborations with noise control engineers inside and outside the federal government. PROGRAM PLANNING Even as the National Academies’ evaluation of up to 15 different NIOSH research programs is under way, NIOSH as a whole is undergoing changes. NIOSH has organized its program portfolio into 8 NORA programs representing industrial sectors, 15 cross-sector programs organized around adverse health outcomes (such as hearing loss), and 7 coordinated emphasis areas (http://www.cdc.gov/niosh/programs/) (NIOSH, 2006). It is developing strategic plans for each of its research programs, and new emphasis is being placed on the translation and application of scientific knowledge to the workplace with the assistance of the NIOSH Office of Research and Technology Transfer. The committee commends NIOSH for its continued striving for improvement as an organization. The Hearing Loss Research Program has acknowledged that until recently it has managed more by opportunity than by objective. Although it may not be feasible for such a small program to manage entirely by objective, and the group

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Hearing Loss Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health has proven itself adept at leveraging opportunities, the committee urges additional efforts to focus its limited resources on its most relevant goals, as discussed in Chapter 2. An important input to this planning can be the research needs of the Occupational Safety and Health Administration (OSHA) and the Mine Safety and Health Administration (MSHA). It appears to the committee that the mechanisms through which the Hearing Loss Research Program anticipates the early research needs of its regulatory partners are not sufficiently consistent and systematic. Although technical staffs at NIOSH, OSHA, and MSHA appear to work well together, there does not seem to be an effective joint planning process for regulatory activities. This is not entirely within NIOSH’s control, but it deserves greater attention in the future. Develop a strategic plan. The Hearing Loss Research Program should develop a strategic plan that takes into account the strengths, weaknesses, and external factors identified in this evaluation. It should reflect a focus on the program’s mission and serve to guide decision making about the value of projects and proposed collaborations. It should also reflect coordination with the strategic plans developed by the sector-based NIOSH research programs that may need to address hearing loss as one of several health hazards faced by the workforce. Use surveillance data as well as stakeholder input to identify priorities. The Hearing Loss Research Program should make the rationale for its research prioritization more explicit, using analyses of surveillance data to the extent possible as well as the concerns and interests of stakeholders from a variety of industrial sectors to guide allocations of resources and effort. Use information from evaluation of hearing loss prevention measures to guide program planning. The Hearing Loss Research Program should use information gained from evaluation of the effectiveness of its program activities to help identify approaches to hearing loss prevention that should be emphasized, revised, or possibly discontinued. Systematize collaboration with regulatory partners. The Hearing Loss Research Program should establish regular means for conferring with OSHA, MSHA, and the Environmental Protection Agency to better anticipate research needs relevant to regulatory decision making.

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Hearing Loss Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health EVALUATION OF HEARING LOSS PREVENTION MEASURES Developing and disseminating “best practices” and training methods for hearing loss prevention programs to apply scientific understanding to the workplace has been an important contribution of the Hearing Loss Research Program and is the focus of Research Goal 1. In its evidence package, the program notes the need for intervention effectiveness research designed to validate best practices for each of the seven components of hearing loss prevention programs advocated by NIOSH (2005). The committee underscores the importance of evaluation of the effectiveness of all program activities, including the dissemination of the educational material that the program develops, as a crucial step in ensuring that the Hearing Loss Research Program serves as a leader in producing evidence-based guidance on hearing loss prevention. Place greater emphasis on evaluation of the effectiveness of hearing loss prevention measures on the basis of outcomes that are as closely related as possible to reducing noise exposure and the incidence of occupational hearing loss. The Hearing Loss Research Program should implement consistent and concerted evaluation activities that inform and focus its work on hearing loss prevention. Prospective evaluations of the recommended components of hearing loss prevention programs are needed to determine which features have the most significant impacts on reducing noise exposure levels or hearing loss incidence rates. These evaluations should address actual (not just intended) worker and employer behavior and the end results of exposure levels and hearing loss. SURVEILLANCE ACTIVITIES The Hearing Loss Research Program notes in its evidence package that the lack of surveillance data on workers’ noise exposures and the incidence and severity of occupational hearing loss is one of the fundamental knowledge gaps in the field. The committee agrees and underscores the importance of surveillance data and their careful analysis to help guide priority setting for research in occupational health and safety and for evaluation of program activities. Although the Hearing Loss Research Program has participated in several different efforts (described in Chapter 2) to address the lack of surveillance data, the current program approaches are piecemeal and require expansion of their conceptual framework and measurement methods. To maintain an appropriate scientific leadership role in the field of occupational hearing loss prevention, the Hearing Loss Research Program needs

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Hearing Loss Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health to increase its emphasis on and expertise in surveillance. Doing so will require resources commensurate with the task. It will also require the leadership of one or more experienced epidemiologists integrated into the program staff (see Recommendation 2 above). Relying on ad hoc epidemiologic assistance is not sufficient. With additional program epidemiology and surveillance expertise, the Hearing Loss Research Program should plan means to gather and analyze new data on the occurrence of hearing loss and hazardous noise exposure. Possible and complementary approaches, as outlined in a recent National Academies report on health and safety needs of older workers (NRC and IOM, 2004), include initiating new longitudinal studies, increasing information gathered from ongoing longitudinal surveys (as the Hearing Loss Research Program has done in working with OSHA), collaborating with the Bureau of Labor Statistics for a comprehensive review of occupational injury or illness reporting systems, and developing a database to characterize levels of exposures associated with work (as the program has been doing for mining). Initiate national surveillance for occupational hearing loss and hazardous noise. The Hearing Loss Research Program should rally expertise and resources to lead surveillance of the incidence and prevalence of work-related hearing loss and the occurrence of exposure to hazardous noise levels in occupational settings in the United States. Surveillance efforts should be accompanied by plans for appropriate analyses of the data. NOISE CONTROL PERSPECTIVE Following the industrial hygiene tradition of the “hierarchy of controls,” noise control engineering should be the primary approach to the prevention of hearing loss. In reality, employers frequently turn first to administrative controls or hearing protection devices to decrease workers’ exposure to hazardous noise. Perhaps as a result, the research emphasis within the Hearing Loss Research Program has also been on aspects of hearing loss prevention other than noise control. Over the past decade, substantially more of the program’s resources have been brought to bear on noise control engineering, but those resources have been directed primarily to the mining industry. Although congressional guidance has resulted in most of this funding being devoted to a single industrial sector, the committee sees it as the mission of the Hearing Loss Research Program to pursue broader applications of its work on noise control engineering. To help identify the potential for broader applications of mining-related work, the committee urges increased collaboration between the Pittsburgh- and Cincinnati-based researchers.

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Hearing Loss Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health Integrate the noise control engineering perspective into overall program efforts for all sectors. The Hearing Loss Research Program should apply its dissemination expertise to further emphasize the application of “quiet by design,” “buy quiet,” and engineered noise control approaches to industrial settings as part of hearing loss prevention programs. Develop noise control engineering approaches for non-mining sectors. The Hearing Loss Research Program should increase efforts to develop noise control approaches applicable in industrial sectors outside mining where workers are also at risk from hazardous noise. Where possible, “dual-use” applications from work done in mining could help bring noise reduction benefit to both miners and workers from other industrial sectors. Increase the visibility of noise control engineering as a component of the Hearing Loss Research Program. The Hearing Loss Research Program should use means such as periodic workshops on noise control engineering topics to raise the visibility of its noise control engineering projects within the field. Such workshops can facilitate information exchange, can provide specialized technical training, and may attract qualified professionals who can serve as advisers, consultants, collaborators, or recruits to the NIOSH program. Accredit laboratories used to conduct studies for the Hearing Loss Research Program. The Hearing Loss Research Program should work to achieve accreditation of all laboratories that are involved in the acquisition of data that are published or shared externally. To the extent possible, testing on behalf of the NIOSH intramural program should be carried out at facilities owned or controlled by NIOSH. EXTRAMURAL RESEARCH Slightly more than $14 million, or about 30 percent of the total expenditures of the NIOSH Hearing Loss Research Program between FY 1997 and FY 2005, was directed toward extramural, competitive application projects related to hearing loss or noise control engineering. With the exception of one Request for Application (RFA) in 2001, the Hearing Loss Research Program has relied on the investigator-initiated pipeline for extramural research projects rather than issuing requests for targeted extramural proposals. The extramural research that has resulted includes important contributions to the knowledge base in this field and has facilitated some productive collaborations with Hearing Loss Research Program researchers. In some cases, however, intramural researchers have not made

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Hearing Loss Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health themselves aware of relevant extramural research, which may have resulted in limited opportunities for effective collaboration. The committee notes the potential for greater use of RFAs and focused Program Announcements (PAs) to direct some extramural funding toward high-priority research topics that complement the program’s intramural work. The Hearing Loss Research Program may also want to further pursue efforts to invite outside researchers to work at NIOSH facilities on a temporary basis and at little cost to the program. The committee recommends the following steps to maximize the benefit that the extramural funding might bring to realizing the mission of the Hearing Loss Research Program. Target more of the extramural research funding. The Hearing Loss Research Program should increase its use of Requests for Applications and focused Program Announcements to target more of its extramural research funding toward program priority areas. Increase collaboration and mutual awareness of ongoing work among intramural and extramural researchers. For the Hearing Loss Research Program to maximize the benefit of extramural research, it is important for intramural and extramural researchers to each be aware of the work that the others are doing relevant to occupational hearing loss or noise control. Where appropriate, intramural researchers should be building upon extramural work within the Hearing Loss Research Program. Toward this end, after a grant has been awarded, NIOSH should facilitate increased communication between intra- and extramural researchers. REFERENCES NIOSH (National Institute for Occupational Safety and Health). 2005. Research Goal 1: Contribute to the Development, Implementation, and Evaluation of Effective Hearing Loss Prevention Programs. In: NIOSH Hearing Loss Research Program: Evidence for the National Academies’ Committee to Review the NIOSH Hearing Loss Research Program. Cincinnati, OH: NIOSH. Pp. 43–75. NIOSH. 2006. NIOSH Program Portfolio. [Online]. Available: http://www.cdc.gov/niosh/programs/ [accessed April 2006]. NRC and IOM (National Research Council and Institute of Medicine). 2004. Health and Safety Needs of Older Workers. Wegman DH, McGee JP, eds. Washington, DC: The National Academies Press.

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