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Agriculture, Forestry, and Fishing Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health 7 Review of Intervention Research The National Institute for Occupational Safety and Health (NIOSH) Agriculture, Forestry, and Fishing Program (AFF Program) has devoted significant resources toward developing and evaluating interventions focusing on the agriculture, fishing, and forestry industries. Review of the program indicates that intervention research-related projects span several of the AFF Program defined goals including those focusing on Priority Populations at Risk (Goal 2), Health Effects of Agricultural Agent Exposures (Goal 3), and Hazard-Control Systems (Goal 4). Given the fundamental importance of intervention research and the noted overlap of activities, the committee decided that it would be appropriate to consider intervention research as a whole, and to collectively evaluate these activities. STRATEGIC GOALS AND OBJECTIVES Goal 2: Priority Populations at Risk—Reduce injuries and fatalities among subgroups of the working population determined to be at high risk or underserved by traditional occupational health approaches. Goal 3: Health Effects of Agricultural Agent Exposures—Determine the chronic effects of agricultural exposures/health outcomes from toxic exposures and develop appropriate interventions to reduce the incidence of disease. Goal 4: Hazard-Control Systems—Reduce injuries and illnesses resulting from work-related exposures by developing, demonstrating, and making available control systems that eliminate, guard against, or warn of the hazard.
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Agriculture, Forestry, and Fishing Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health The intervention-research aspects of the AFF Program’s goals align well with high-priority research subjects identified in the National Occupational Research Agenda (NORA), including control technology and personal protective equipment and intervention effectiveness in the category of research tools and approaches. The research goals are general and do not include specific measurable objectives or stated strategies for accomplishing the goals. NIOSH relies largely on NORA and the peer-review process to ensure the relevance of funded intramural and extramural projects. However, the process lacks formal mechanisms for coordinating research efforts in a scientific community that includes NIOSH scientists and engineers and extramural investigators in the NIOSH Centers for Agricultural Disease and Injury Research, Education, and Prevention (Ag Centers) and other research institutions and centers. The current NORA-2 process for establishing the goals and objectives of the AFF Program needs to ensure relevance. The current strategic goals of the AFF sector defined under NORA-2 are in development. In addition, the process through which the NORA sector councils are being developed needs to ensure that emerging problems are identified through interaction and communication with stakeholders. It seems likely that the establishment of an AFF sector in NORA will ensure that the research programs align with priorities established through the NORA-2 development process. LOGIC SUBMODEL Information received from the NIOSH AFF Program (NIOSH, 2006a) related to inputs, activities, outputs, intermediate outcomes, and end outcomes in intervention research is summarized in the intervention research logic submodel (Figure 7-1). INPUTS Funding for intervention research has been provided through cooperative agreements, extramural grants, and internal funding of specific projects. ACTIVITIES The major subprograms related to intervention research are listed in Table 7-1 with approximate dates and funding levels. The Ag Centers are listed as a whole, because detailed project information was not available by individual center. The activities are consistent with intervention research, which is an element of several AFF Program goals, including those related to high-priority populations, chemical exposure, hazard control, and outreach.
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Agriculture, Forestry, and Fishing Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health FIGURE 7-1 Intervention research logic submodel. AgDARE =Agricultural Disability Awareness and Risk Education, ASABE = American Society of Agricultural and Biological Engineers, FACE = Fatality Assessment and Control Evaluation, NAGCAT = North American Guidelines for Children’s Agricultural Tasks, PPE = personal protective equipment, ROPS = rollover protective structure.
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Agriculture, Forestry, and Fishing Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health TABLE 7-1 Programs with Intervention Research Activities Program or Project NIOSH Division Dates Funding ($) Community Partners for Healthy Farming Intervention Research DSHEFS 1996-2007 6,550,341 Childhood Agricultural Injury Prevention, National Children’s Center for Rural and Agricultural Health and Safety (NCCRAHS) DSR 1996-2010 1,107,379 Occupational Injury Prevention in Alaska—Commercial Fishing, Helicopter Logging AFS 1990-2010 3,388,092 Ergonomic Interventions for Youth Working in Agriculture DART 2000-2006 370,104 Evaluating the Effectiveness of a Logger Safety Training Program DSR 2000-2004 205,403 Deck Safety for Commercial Fishing Vessels AFS 2004-2006 198,424 Environmental Tractor Cab System Integrity DRDS 2001-2005 778,570 Emerging Agricultural Problems—Effectiveness of Hand Washing in Reducing Agricultural Worker Exposure to Pesticides DSHEFS 1996-2004 1,078,076 Cancer Control Demonstration Projects for Farming Populations DSHEFS 1990-1997 >46,304 New Technology to Increase ROPS Use on Tractors DSR 2000-2006 1,222,948 Development of Automatic ROPS DSR 1992-1999 392,545 Development of Automatic ROPS Overturn Sensor DSR 1994-1999 484,492 Commercialization of a Cost-Effective ROPS (CROPS) Design DSR 2003-2004 122,825 Anthropometry of Agriculture Populations DSR 1996-2003 718,369 Agricultural Safety Promotion System DSR 1995-1997 1,000,000 Ag Centers OEP 1997-2006 74,885,568 NOTE: AFS = Alaska Field Station, DART = Division of Applied Research and Technology, DRDS = Division of Respiratory Disease Studies, DSHEFS = Division of Surveillance, Hazard Evaluations, and Field Studies, DSR = Division of Safety Research, OEP = Office of Extramural Programs. Relevance to Most Serious Outcomes The intervention research activities generally focus on the most serious outcomes. According to the Worker Health Chartbook, the five leading sources of occupational fatalities in AFF in 1992-2001 were farm tractors (2,165), trucks (795), fishing boats (434), ground (403), and trees and logs (357) (evidence package Table 2-3, NIOSH, 2004). A large portion of AFF Program activities was devoted to intervention research designed to address the most serious outcomes.
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Agriculture, Forestry, and Fishing Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health Tractor Fatalities In the case of tractor fatalities, primary research emphasis has been on the development and evaluation of rollover protection structures (ROPS). Intramural projects focusing on ROPS were conducted by personnel in the Division of Safety Research, including New Technology to Increase ROPS Use on Tractors, Development of Automatic ROPS, Development of Automatic ROPS Overturn Sensor, and Commercialization of a Cost-Effective ROPS (CROPS) Design. Cooperative agreement research focusing on tractor interventions was conducted through the Community Partners for Healthy Farming Intervention Research, which supported such projects as the Kentucky ROPS programs (I and II) and Electronic Tractor and Machinery Safety Training Material for Youth. The Ag Centers also contributed resources to the development of interventions to prevent tractor and equipment injuries; projects included ROPS Design and Testing for Agricultural Vehicles (High Plains Intermountain Center for Agricultural Safety and Health), Cost-Effectiveness of Promoting Rollover Protective Structures (ROPS) and Seat Belts on Family Farm Tractors (Southeast Center for Agricultural Health and Injury Prevention), Tractor Safety Program (The Northeast Center for Agricultural and Occupational Health), an Audiovisual Approach to Train WV Farmers on Prevention Effectiveness of ROPS in Reducing Traumatic Injury (Great Lakes Center for Agricultural Safety and Health), Tractor Risk Abatement and Control (TRAC-SAFE) (Great Plains Center for Agricultural Health), and Youth, Tractors, and Policy (National Children’s Center for Rural and Agricultural Health and Safety). In addition, a National Agricultural Tractor Initiative involving a collaboration of all the Ag Centers and the National Children’s Center began in 2005; its goals are to establish incentives to retire older tractors or retrofit them with ROPS, increase the use and maintenance of preventive and protective technologies, mount a social marketing campaign aimed at safer tractor use, and build private-sector and legislative support. Fishing Vessel Fatalities Intervention research related to fishing vessel fatalities has been the focus of several intramural and extramural projects, including Commercial Fishing Safety Training in Alaska: 1993-2006, Injury Prevention in the Commercial Fishing Industry (at the Alaska Field Station, AFS), Deck Safety for Commercial Fishing Vessels (AFS), and Occupational Injury Prevention in Alaska (AFS).
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Agriculture, Forestry, and Fishing Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health Logging Fatalities The AFF Program has adopted a multipronged approach to control injuries in logging, consisting of support for development of an Occupational Safety and Health Administration (OSHA) standard for the logging industry, coordination of an Alaskan intervention program to address injuries associated with helicopter operations, conduct of investigations of selected logging fatalities with the Fatality Assessment and Control Evaluation (FACE) program, and assessment of mechanical logging methods as a means of reducing injuries. Relevance to Most Frequent Outcomes The 2004 Worker Health Chartbook indicates that the number of nonfatal agricultural injuries has been increasing; they totaled 104,400 in 2001. On the basis of data gathered from 1993 to 1995, the leading sources of injury were machinery and livestock, with roughly equal numbers attributed to each (about 99,000). The largest number of injuries occurred in cattle, hog, or sheep operations, followed by cash-crop and dairy farms. The Chartbook also presents nonfatal injury data from the 11 NIOSH surveillance and research areas. Results show that relative to other industries, the AFF sector had relatively high rates in the surveillance categories of fatal injuries, nonfatal injuries (particularly amputations, back injuries, bruises and contusions, cuts and lacerations, fractures, and strains, sprains, and tears), poisoning (with pesticides), respiratory disease (especially hypersensitivity pneumonitis), and dermatitis. It is noted that surveillance data on many of these categories are quite sparse. The AFF Program has supported numerous intervention research activities directed toward the most common outcomes. The projects reflect diverse targeted outcomes that in general are relevant to the most common outcomes identified in the Worker Health Chartbook or through surveillance activities conducted as part of other Ag Center activities. Relevance to Needs of Special Populations Gender is often included in examinations of risk factors for injury and illness, but no evidence was found to suggest that it was being specifically considered in the intervention research projects examined. Vulnerable working populations were often the focus of AFF Program intervention projects, including the extensive emphasis on childhood agricultural injury prevention, migrant and minority populations, loggers, and fishermen.
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Agriculture, Forestry, and Fishing Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health Partnerships in Research Activities The AFF Program partners extensively with numerous organizations at the national and local levels in conducting intervention research. There are numerous examples of diversity in partnerships in terms of the size of the organizations involved and the nature and scope of the projects. A detailed list of federal agency partnerships established for high-priority populations at risk is found in Table 7-2. On the basis of the extensive partnerships described, it is clear that this aspect of the AFF Program is one of its strengths and that it probably results in numerous synergies that increase overall effectiveness. TABLE 7-2 Federal Agencies Partnering with the NIOSH AFF Program on High-Priority Populations at Risk CHILDHOOD AGRICULTURAL INJURY PREVENTION Centers for Disease Control and Prevention, Division of Community and Migrant Health Centers Consumer Product Safety Commission Health Resources and Services Administration (HRSA), Maternal Child Health Bureau Indian Health Service National Center for Injury Prevention and Control National Institute of Child Health and Human Development U.S. Department of Agriculture (USDA), National Agricultural Statistics Service (NASS) USDA, Cooperative State Research, Education, and Extension Service U.S. Department of Education, National FFA Adviser U.S. Department of Education, Office of Migrant Education U.S. Department of Labor (DOL), OSHA DOL, Employment Standards Administration DOL, Employment and Training Administration MINORITY-POPULATION PROGRAMS DOL, OSHA Food and Drug Administration HRSA Navajo Chapter Houses National Cancer Institute USDA-NASS U.S. Environmental Protection Agency (EPA) FISHING SAFETY RESEARCH Alaska Marine Safety Education Association (AMSEA) Harvard School of Public Health North Pacific Fishing Vessel Owners’ Association U.S. Coast Guard SOURCE: NIOSH, 2006a.
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Agriculture, Forestry, and Fishing Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health Appropriateness of Resource Allocations It is difficult to find a coherent theme in some of the projects that have been funded over the period examined. Historically, some Ag Centers seem to have taken on a large number of varied projects that do not necessarily represent a subject of focus. The most recent request for applications for Ag Centers is structured in such a way as to ensure that center programs have a focus or theme, that intervention projects are fully developed, and that process and outcome measures are included. Furthermore, the requirement that at least 20 percent of Ag Center direct costs be devoted to prevention and intervention research ensures a substantial commitment to this kind of research in the future. Planned Program of Transfer Activities There is not a single, coherent, AFF Program-wide plan for intervention research transfer. Plans for transfer activities may be included in individual projects, and in some cases the projects themselves may focus entirely on transfer activities, but there is no unified strategy for transfer of AFF Program intervention research. OUTPUTS The major outputs from intervention research activities are publications, reports, conferences, databases, engineering designs, guidelines, recommendations, education and training materials, scientific manuscripts, and product dissemination. Intervention research outputs addressed a variety of outcomes, including such high-priority subjects as tractor-related, fishing, and logging fatalities. In addition, many outputs were developed to reduce injury and illness related to tractors and equipment, livestock, musculoskeletal disorders, and pesticide exposure. High-Priority Subjects Tractor-Related Injury Intervention Research This research has produced numerous outputs aimed at reducing tractor-related fatalities through the Community Partners for Healthy Farming Intervention. It supported the Kentucky ROPS project, which produced a notebook “toolkit” for promoting ROPS-equipped tractors (Ehlers and Palermo, 2005). The project led to more than 10 peer-reviewed publications and electronic and paper versions of training materials in different languages. Several Ag Centers have also focused intervention research efforts in tractor-related injury.
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Agriculture, Forestry, and Fishing Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health Fishing Vessel Fatalities Intervention research outputs related to reducing fishing fatalities were produced primarily through the AFS (Injury Prevention in the Commercial Fishing Industry, Deck Safety for Commercial Fishing Vessels, and Occupational Injury Prevention in Alaska—Commercial Fishing), Ag Centers (Skin Disorders in Commercial Fishermen and Understudied/Under-Represented Populations—Vietnamese Shrimpers), and an extramural project (Commercial Fishing Safety Training in Alaska: 1993-2006). Outputs included abstracts, posters, brochures, patents, peer-reviewed publications, a 450-page marine safety training manual, and multilingual DVD and videotaped training materials. Logging Fatalities Intervention-research outputs directed at reducing fatalities in logging included peer-reviewed publications; NIOSH publications, including FACE reports; criteria for a recommended standard; and conference papers and presentations. Musculoskeletal Disorders and Ergonomics Many intervention-research outputs focusing on ergonomics and musculoskeletal disorders (MSDs) have resulted from the AFF Program, including the following: Community Partners for Healthy Farming Intervention Research: Ergonomic Interventions in Wine Grape and Tree Fruit Production Healthy Farmers-Healthy Profits—direct-market vegetable producers Healthy Farmers-Healthy Profits—tame berry producers in six upper Midwest states Ergonomic Interventions for Youth Working in Agriculture Agricultural Safety Promotion System: effectiveness of ergonomic interventions in nursery operations Western Center for Agricultural Safety and Health: Improving Health and Safety of Field Workers by Redesigning Tools Prevention of Musculoskeletal Disorders in Hand Harvest of Vegetable Crops Evaluation of the Ergonomics of an Alternative System for Harvesting Pears Efficacy of Weight Transfer Devices in Reducing Low Back Pain in Stoop Labor
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Agriculture, Forestry, and Fishing Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health Southern Coastal Agromedicine Center: Ergonomic Interventions in the Agriculture Industry The Northeast Center for Agricultural Health: Musculoskeletal/Ergonomic Program Pacific Northwest Agricultural Safety and Health Center: musculoskeletal disorders In addition, a conference focused on stooped and squatting postures in the workplace was jointly sponsored by the University of California Center for Occupational and Environmental Health, the University of California Agricultural Ergonomics Research Center, NIOSH, the California State Compensation Insurance Fund, and the Center to Protect Workers’ Rights (Stooped and Squatting Postures in the Workplace, Oakland, CA, July 29-30, 2004). Pesticide Exposure Intervention research outputs related to pesticide exposure were produced by such projects as Interventions To Reduce Pesticide Exposures Among Agricultural Workers and Their Families (Pacific Northwest Agricultural Safety and Health Center) and Emerging Agricultural Problems—Effectiveness of Hand Washing in Reducing Agricultural Worker Exposure to Pesticides (Division of Surveillance, Hazard Evaluations, and Field Studies). Generation and Dissemination of New Knowledge Considered as a whole, the AFF Program has generated considerable amounts of new technology and knowledge related to interventions, although the quantity and quality of the outputs are highly variable. Numerous peer-reviewed publications have been produced, and many have been presented in flagship journals and widely cited. The diverse nature of the journals suggests that outputs reach a wide and varied audience and that investigators are choosing publications believed to be best aligned with the content of and relevant stakeholders for the projects described. Relevance of Outputs to Both Sexes, Vulnerable Populations, and Health Disparities Intervention research outputs included publications that were relevant to both sexes, vulnerable populations (children, fishermen, loggers, and orchard workers), and health disparities (skin cancer).
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Agriculture, Forestry, and Fishing Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health Relevance of Outputs to Small Businesses Outputs are relevant to small businesses. It is well recognized that two of the most important challenges in developing interventions for agriculture, forestry, and fishing is that most operations are small and that effective regulation and comprehensive surveillance programs do not exist. Most of the outputs produced are relevant to or specifically produced for small operators. Readability, Simplicity, and Design of Outputs Intervention research outputs intended to be delivered to AFF workers have generally been designed with the end user in mind. Materials examined were appropriately readable and user-friendly. The North American Guidelines for Children’s Agricultural Tasks (NAGCAT) was developed to guide parents in assigning farm jobs to children 7-16 years old. The guidelines are targeted for use by parents, agricultural safety specialists, educators, youth groups, health professionals, farm organizations, public health professionals, and the mass media. The guideline booklets are user-friendly with respect to readability, simplicity, and design. Materials developed for migrant and minority-group orchard workers have been included in the National Agriculture Safety Database, such as educational and informational resources organized by topic, language, and format (for example, fact sheet, news releases, and script). Whether this is the most effective manner to reach these workers is not clear. These examples make up only a small portion of the intervention research outputs produced, but they demonstrate an awareness of the need to prepare materials in a user-friendly manner that is appropriate for the intended audience with some exceptions such as the migrant workers who do not use computers as a source of information and may have low English or Spanish literacy. INTERMEDIATE OUTCOMES AFF Program intervention research activities have resulted in numerous training and education outputs that are being used in the workplace or in school or apprentice programs. They have also led to the development of standards, regulations, public policy, and voluntary guidelines that have been transferred to or created by the workplace in response to NIOSH outputs. Furthermore, new control technology, personal protective equipment, and administrative control concepts that are feasible for use have been adopted in the workplace to reduce risk factors. Although objective data are difficult to obtain, results generally indicate that stakeholders find value in AFF Program intervention research products, as indicated by
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Agriculture, Forestry, and Fishing Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health document requests, Web hits, conference attendance, and anecdotal reports and feedback. Evidence suggests that program activities have resulted in many research partnerships with stakeholders that have led to changes in the workplace and that interventions that protect both sexes and vulnerable workers and that address the needs of small businesses have been developed. Standards, Regulations, Public Policy, and Voluntary Guidelines The AFF Program has produced several examples of standards, regulations, public policy, and voluntary guidelines related to intervention research. Those outputs include revised or proposed standards related to ROPS for tractors, legislation providing rebates for ROPS retrofits, sales tax exemptions for purchase of personal protective equipment, guidelines for children’s agricultural tasks, and support for development of a statewide cholinesterase-monitoring program and a federal logging standard. New Personal Protective Equipment Developed The AFF Program has developed a prototype improved personal flotation device that has thin, flexible patches that become illuminated once the personal flotation device or jacket is submerged and allow quick location and recovery of victims. Unique Staff and Laboratory Capability The High Plains Intermountain Center for Agricultural Health and Safety and the NIOSH Pittsburgh Laboratory for designing and testing engineering control strategies for tractors and other agricultural equipment house unique capabilities among the Ag Centers and other institute and agency resources. END OUTCOMES Demonstrating the impact of intervention research is challenging and complex given the considerable time often required for a measurable impact on population illness and injury rates to occur. Furthermore, most diseases and injuries have multiple causes, and the adequacy of surveillance varies with changes in access to healthcare and economic disincentives to report. For those reasons it is difficult to attribute end outcomes directly to specific intervention research projects. However, there are some encouraging trends in injury and illness data that are consistent with a favorable impact. For example, since the release of NAGCAT in 1999, the work-
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Agriculture, Forestry, and Fishing Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health related injury rate in farm household youth decreased from 14.1 to 9.1 injuries per 1,000 working household youth from 1998 to 2004. After the release of a proposed OSHA logging standard in 1989, the national occupational injury and illness rate in the logging industry decreased from 19.5 to 6.4 cases per 100 full-time workers in 2003. NIOSH also played a lead role in developing the Alaska Working Group’s July 1993 recommendations to prevent helicopter logging crashes. Since that time, there has been only one helicopter logging crash in Alaska (it occurred in 1996). Although it is recognized that the work-related fatality rate in commercial fishing in Alaska remains unacceptably high, historical data show that fatalities are decreasing. NIOSH reports that since 1990 there has been a 74 percent decline in annual deaths in Alaska’s commercial fishermen. Extensive collaboration with U.S. Coast Guard and numerous other partners in Alaska to implement new safety requirements probably contributed substantially to the 96 percent survival rate of commercial fishermen involved in vessel sinkings and capsizings in 2004; the survival rate was only 73 percent in 1991. NIOSH also reports that a pilot eye injury prevention project funded by the AFF Program in Florida helped to reduce eye injuries (by 75 percent) in 500 workers from 2003 to now. The project also found that the rate of acceptance of safety glasses increased to 65-75 percent from 5 percent before intervention. Those end outcomes are only a sample of the outcomes attributed to AFF Program intervention research. EXTERNAL FACTORS Programs engaged in intervention research have described various external factors relevant to the AFF sector. These external factors include: the seasonality of work tasks which often provides only short windows of time for data collection; multiple years that are needed to demonstrate effective intervention results; weather variations that influence activities across years; and workers that are willing to take risks and lack awareness of the preventability of illnesses and injuries. Other variables include: rapid changes in the work practices under study; time needed to build relationships with partners and constituents; market conditions; current political climate and uncertainty regarding immigration issues; and a poor national and political understanding of the scope of and costs related to occupational disease and public health.