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Agriculture, Forestry, and Fishing Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health 2 The Ideal Agriculture, Forestry, and Fishing Research Program As its first step in evaluating the National Institute of Occupational Safety and Health (NIOSH) Agriculture, Forestry, and Fishing Research Program (AFF Program), the committee was directed by the Framework Document to independently identify the major program challenges for an occupational safety and health research program in agriculture, forestry, and fishing. The committee relied on surveillance findings and its expert judgment to determine the major components of an “ideal” research program that would cut across the three sectors. This chapter outlines the committee’s deliberations regarding the ideal safety and health research program in agriculture, forestry, and fishing and provides a methodology for the program to fulfill its congressional mandate. The committee used the ideal program as a benchmark to measure the goals and activities of the existing NIOSH AFF Program, which is assessed in Chapters 3-10. OVERARCHING PROGRAM CHARACTERISTICS The ideal NIOSH AFF Program would have adequate resources to set priorities among and accomplish the congressionally stated goals of surveillance, research, and intervention through (1) identification and characterization of injuries and illness and detailed characterization of populations at risk through surveillance; (2) identification and characterization of special populations and the unique health and safety risks they face; (3) identification and characterization of health effects associated with chemical, physical, and biological agents encountered in agricul-
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Agriculture, Forestry, and Fishing Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health ture, fishing, and forestry; (4) identification, development, evaluation, and implementation of control systems to reduce injury and illness; and (5) development of efficient and effective outreach mechanisms for dissemination and delivery of knowledge developed through research. Those resources would include adequate staff, scientists, engineers, and administrators who work together with clearly defined goals, strategies, and evaluation methods to ensure success in achieving AFF Program goals. Their combined experience and expertise would be specific to agriculture, fishing, and forestry, to the extent possible. There would be clearly defined reporting mechanisms and procedures for maintaining accountability, and a well-organized system would be in place for creating an archive of program work products for future reference. A single person would be charged with directing the entire program and overseeing, evaluating, and communicating its plans. However, content experts would be in charge of each arm of the program: a separate leader for agriculture, for forestry, and for fishing. The committee envisions a relatively flat organization chart; the person in charge of each arm would have a fair amount of responsibility to make decisions. The management matrix or organization structure would be flexible so that the AFF research teams can recognize and react quickly to changes in the AFF industries, the economy, new technologies, and relevant results of research in other programs, and managed in such a way that AFF research teams are encouraged to be proactive in anticipating and mitigating emerging risks and hazards. The AFF Program would be informed of current issues through contacts in the U.S. Department of Agriculture, Cooperative Extension System, and industry representatives. The AFF Program would have world-class research facilities and laboratories devoted to solving problems specific to the strategic plan. The facilities would focus on elements of the strategic plan that may not be adequately addressed through extramural research projects, such as the development of analytic methods directly relevant to the AFF mission. AFF resources would not be used to duplicate capabilities available in partner agencies or programs or when the foremost expertise is available through extramural programs. In addition to projects funded at the NIOSH Centers for Agricultural Disease and Injury Research, Education, and Prevention (Ag Centers), the AFF Program would consider funding extramural projects that address important issues and innovative technologies. The AFF Program would include the means to fund large multicenter studies to answer scientific questions that cannot be addressed any other way; an example might be gene-environment interaction studies, which have become important in fields ranging from the risk of lumbar disk herniation to the risk of airway obstruction related to animal feeding operations. Ethical issues related to findings from gene-environment interaction studies would be considered, including the possible impact on employment.
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Agriculture, Forestry, and Fishing Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health Resources would be distributed among the three industries covered by the program according to appropriate measures of impact, such as numbers and types of fatalities and nonfatal injuries and illnesses, and the application of objective metrics of direct and indirect costs. Appropriate resource distribution requires a complete understanding of populations at risk, and requires surveillance to characterize injuries, illnesses, and associated costs and to detect new trends. Surveillance methods specific to the regions of the population at risk would be used to ensure adequate coverage. Strategies for developing new objective approaches to measure the socioeconomic impact of work-related injury and illness would be established. The ideal AFF Program would be highly visible in the industries covered at federal, state, and local levels. The program would have representation across the country in numbers proportional to the population at risk. The program would form partnerships with existing agencies, universities, or other organizations that have complementary missions and would leverage infrastructure and relationships toward accomplishing its goals, with emphasis on surveillance and outreach. The ideal program would address the research needs of large, medium, and small-sized operations. Large corporations produce most of our food and fiber products, are able to harness resources to implement many recent technological developments, and would be viewed as valuable partners of NIOSH. Program evaluation procedures that use both internal and external reviews would be conducted at regular intervals. A short summary of the reviews would be accessible to the public. SPECIFIC PROGRAM COMPONENTS When considering the ideal research program, the committee focused its efforts on identifying the following program components that would comprehensively and effectively address the safety and health issues that face workers in agriculture, forestry, and fishing: Identify and engage stakeholders, Identify populations at risk, Conduct surveillance, Conduct health effects research, Conduct intervention research, Conduct health services research and training, Conduct research on knowledge diffusion and technology transfer, Inform public policy and provide regulatory assistance, Conduct program evaluation initiatives.
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Agriculture, Forestry, and Fishing Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health Stakeholders The occupational safety and health program for the AFF industries would be founded on an understanding of and respect for the unique characteristics of the AFF communities. Healthy and safe workers and families are the foundation of the economic and social well-being of the industries. Government, private, academic, and healthcare professionals all have unique strengths that complement those of the AFF Program, and all parties are needed to maximize its effectiveness. The program would be participatory and community- or work population-based and have the support of the AFF community so that there is buy-in for research intervention developments. The program would also empower the community to action so that involvement goes beyond involving stakeholders merely at the beginning and end. The concept of broader deliberation and decisionmaking among researchers and populations at risk from the inception of research ideas to their completion as applications would be explored more in-depth. Partnership and collaboration with stakeholder groups are integral to favorable change and improved outcomes. Involving these groups would enable the AFF Program to “think outside the box”; stakeholder involvement is especially important when researchers devise various ways to reach AFF workers for input. Regional priorities would be developed in collaboration with carefully selected community study groups in each U.S. Department of Agriculture region where a substantial portion of the identified population at risk resides and works. For example, a state-level or regional community study group would include representatives of each of the five types of workers (see Populations at Risk section within this chapter for worker classification). The private sector—including the agricultural service and supply industries, insurance companies, private foundations, legal services providers, industry trade associations, ethnic self-help groups, and community service organizations—is an essential part of an effective national strategy. Careful selection implies that both organizational representatives and unaffiliated individual workers will be represented. It is expected that community study groups will also monitor and report to the public on the progress of the program. A reasonable allocation of program resources to staff and nurture these groups will be required to support a successful long-term effort. Special efforts will be required to include full participation of and direct representation of non-English speaking workers, whether self-employed or hired. Surveillance A successful surveillance program requires knowledge about the size, distribution, and characteristics of “at-risk” populations. That would be followed by systematic analysis of data and surveillance of hazards, injuries, and illnesses. NIOSH
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Agriculture, Forestry, and Fishing Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health AFF Program staff would routinely provide surveillance data so that intervention initiatives can be appropriately targeted. Furthermore, periodic evaluation of AFF surveillance mechanisms is needed to update procedures as work practices, hazards, diseases, injuries, and worker populations change. Health and hazard surveillance is central to the design of interventions for the AFF sectors. Surveillance would be broad in light of the diversity of settings, employment practices, and populations, such as female spouses, the elderly, and children. Datasets would include demographic characteristics to assist in the identification of populations at risk. It has been noted that “hazard surveillance is the assessment of the occurrence of, distribution of, and secular trends in levels of hazards (toxic chemical agents, physical agents, biochemical stressors as well as biological agents) responsible for disease and injury” (Halperin et al., 1992). Surveillance would be continuous to monitor the effects of technological changes, geographic and other shifts in production, policies, population changes, and market forces that affect AFF worksite organization and management. On occasion, special non-routine surveillance efforts would be launched to address rapidly emerging developments and unique populations of workers. Surveillance is the cornerstone of a successful long-term program; it is a means of identifying dangerous conditions and monitoring trends in AFF industries and is aimed at prevention and knowledge translation. Surveillance of important risk factors for injury and illness would be continuous so that the effects of technological change, geographic and other types of shifts in production, population changes, and other external factors can be monitored. Surveillance will rely on various sources: in addition to federal or other government institutions, other sources would be consulted, such as workers’ compensation insurance records, death certificates, and hospital emergency room records. Trade association meetings and conferences can also provide useful information on current trends. For some industries and populations, it may prove necessary to commission special surveillance studies. Such studies would be initiated by a group of experts who meet jointly with carefully selected spokespersons representing important subgroups of the population of interest. The surveillance effort would regularly produce summary reports that are carefully designed in collaboration with experts and that are made available to the public through the Internet. Each AFF project would have priorities in surveillance for not only gathering data but analyzing findings to assist NIOSH in establishing research and intervention priorities. Populations at Risk Risk exposure is a component of research in occupational safety and health. It is fundamental that increased risk exposure leads to a greater incidence of
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Agriculture, Forestry, and Fishing Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health occupational injury or illness. Injury and disease rates in occupational settings would be computed to appropriately assess populations that are at higher or lower risk of exposure. Rate computation requires knowledge of the number of people at risk (the denominator). Assessing the number of AFF workers by race or ethnicity, age, and gender requires use of information outside traditional occupational safety and health data collection systems. Unlike nearly all other major industry sectors, the AFF workforce is comprised of mostly self-employed and seasonally employed workers. In addition, because of the reliance on natural resources for production, there are millions of distinct AFF worksites: farms, forests, and fishing vessels on open waters. The ideal AFF Program would have thorough, accurate, and up-to-date knowledge of the AFF workforce. The size, geographic distribution, seasonal variations in employment, and demographic characteristics of the overall population and of substantial groups would be identified with reasonable precision. There are five types of workers to consider (some examples of each are indicated): Self-employed workers (such as farmers, ranchers, fishermen, and loggers). Unpaid family workers (such as spouses, adult children, and children under 18 years old). Direct-hire workers (such as farm laborers, fishing vessel crews, and lumber company employees). Contract-hire workers (such as labor contractor employees, custom harvesters, and service company employees). Workers employed by larger-scale businesses. AFF workplaces are, by their relationship to natural resources, extensive as opposed to localized; therefore, other persons may be at risk owing to their residence on or next to worksites. They may include children, spouses, or other kin of AFF workers. Minors, whether they are unpaid family workers or hired workers, are of special concern in the AFF workforce. Non-working minors who reside on a farm, near crop fields, or adjacent to livestock facilities are also of concern as they may face exposure to hazards normally associated with employment. The occupational safety and health of minors working in agriculture is addressed in federal law and in several state laws (see Appendix F). A few farm family health and hazard surveillance studies have included women in the study populations, and reports have been published on work-related injuries (Xiang et al., 1997; Stallones and Beseler, 2003). Some studies have documented the extent of women’s contribution to work in agriculture and their risk of injuries (Engberg, 1993; Xiang et al., 1997; Reed et al., 1999; McCoy et al., 2001; Stallones and Beseler, 2003; Stallones, 2004); however,
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Agriculture, Forestry, and Fishing Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health little has been done in either forestry or fishing. The ideal program’s extramural research review process would include gender-related studies, because women have thus far received little attention as a group of concern. The committee established a detailed analysis for the ideal AFF Program to identify various AFF workforce populations in Appendix E. Health Effects Research Investigation of health effects in AFF would be the foundation of the AFF Program. Health effects to be studied include those caused by physical, chemical, and biological hazards. The health effects would include traumatic injury, hearing loss, cancer, musculoskeletal conditions, lung disorders, dermatological conditions, psychosocial effects, mental health disorders, and zoonotic diseases. Tuberculosis is a persistent problem and would also be studied in AFF workers, because it is transmitted in the work setting and disproportionately affects AFF workers. The physiological effects of working in extreme temperatures and of exposure to vibration from tools would also be explored in AFF workers. The relationship between incentive pay, worker productivity, and product quality has been studied (Billikopf, 1985), but the health effects of incentive-based pay systems—such as piece rate that is widely used in agricultural harvest work and other forms of incentives to increase worker productivity—remains unknown and needs to be examined. There is also an urgent need to investigate the effects of shift work and other causes of work-related sleep deprivation on AFF workers. The results of all those studies will be the foundation of intervention research in the AFF Program. A key element of intervention research is to disseminate research findings to AFF workers, company safety officers, Cooperative Extension agents, and public health workers. The existing NIOSH Ag Centers could play a larger role in this effort than they have to date. Means of disseminating information relevant to forestry and fishing will have to be devised. Accurate evaluation of the results of the dissemination effort would be part of the dissemination plan. Epidemiological research, toxicological research, laboratory-based physical and safety risk factor research, and exposure assessment research would be conducted as part of the ideal AFF Program. Epidemiological Research An ideal research program would use the surveillance results to identify target illnesses for further epidemiological study. Appropriate study designs for discerning disease associations and causation, such as long-term prospective cohort studies, would be used in such a way as to ensure that results are applicable to the overall population and important subpopulations. The ideal AFF Program would conduct population-based studies with adequate staffing to define a variety of health effects
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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 to production AFF. This effort would require a large financial commitment and careful coordination on a local and national level. Some critical work aimed at answering many important questions can be done only with a multicenter approach. The ideal program would explore emerging topics, including genetic susceptibility to health effects of AFF exposures. Gene-environment interactions relevant to various illnesses and injuries common in AFF workers would be explored with a combination of laboratory and clinical methods in the new field of genetic epidemiology. The risk of zoonotic disease transmission has emerged as a concern; specifically, there have been several cases of avian influenza A (H5N1) transmission from birds to humans in Asia and Europe (CDC, 2007), and this could emerge as a threat to U.S. poultry handlers if the disease spreads to the United States. Challenges to conducting large epidemiological studies include the resources required and the diversity of the AFF industries with regard to regions, occupations, methods, and exposures. Existing collaborations between NIOSH and other agencies conducting the Agricultural Health Study could be expanded to avoid duplication of efforts. Toxicological Research The ideal AFF Program would have partnerships with other agencies and organizations, including chemical manufacturers, to ensure that toxicological studies are performed to characterize mechanisms of health effects and disease in connection with all exposures relevant to AFF occupations. Challenges would include the resources required for detailed toxicological studies, the logistics of partnering with other agencies to influence direction, and the large number of chemical, physical, and biological agents to which AFF workers are exposed. Laboratory-Based Physical and Safety Risk-Factor Research The ideal AFF Program would have access to state-of-the-art laboratory facilities adequately equipped to conduct the research needed to characterize safety risk factors for each AFF occupation. The program would also work closely with the manufacturers of equipment identified as being most often associated with injury exposure. Challenges include the resources required, including physical facilities, technical expertise, and partnerships with equipment manufacturers. Exposure Assessment Research The ideal AFF Program would have projects in place to ensure that exposures to physical, chemical, and biological agents in the AFF industries that cause injury or illness are fully characterized. Typical exposures, ranges of exposures, and exposure
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Agriculture, Forestry, and Fishing Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health distributions would be characterized. The ideal AFF Program would develop convenient and effective clinical methods for detecting and characterizing exposures and disease in the populations at risk. Tests would be economical, noninvasive, field-ready, and reliable. Exposure assessment algorithms would be developed for use in retrospective epidemiological studies and prospective studies. Ideally, exposure assessment would be a continuous part of prospective cohort studies. Where resources limit the establishment of large cohorts, exposure assessment activity on a smaller scale would form the basis of algorithms for use in quantifying exposure in epidemiological studies. Challenges include financial resources, technical expertise and limitations in available technology, the variability of exposures among the different AFF occupations, and the extreme diversity of chemical, physical, and biological agents to which workers are exposed. The ideal AFF Program would take into consideration the complex mixtures of chemicals and environmental factors to which workers are routinely exposed. Intervention Research Intervention research has been described as the study of planned and applied activities designed to achieve desired outcomes (Goldenhar and Schulte, 1994), and focuses on the examination of the efficacy of new and existing prevention strategies in the workplace (Rosenstock, 1996). In explaining a commitment to increase extramural and intramural support in 1996, NIOSH Director Linda Rosenstock stated that it was important for NIOSH to use intervention research more aggressively to provide a mechanism of evaluation that goes beyond investigation, identification, and recommendations (Rosenstock, 1996). Given the focus on intervention research and the development of guideline documents for evaluating the effectiveness of interventions (see Figure 2-1) (Goldenhar et al., 2001; Robson et al., 2001), it is appropriate to consider an ideal or benchmark intervention research program in describing the ideal AFF program. The ideal or benchmark intervention research program would have the following characteristics: A comprehensive surveillance program to ensure that the incidence of acute and chronic illness and injury, relevant exposures and risk factors, and the affected populations can be fully characterized. Funding, facilitation, and promotion of intervention research that focuses on the highest-priority populations and problems (identified through surveillance) and that is conducted according to established and accepted theory and frameworks related to development, implementation, and evaluation.
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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 2-1 The intervention research framework and phases. SOURCE: Adapted by L.M. Goldenhar from Goldenhar et al., 2001. Funding mechanisms that allow for the evaluation of long-term effectiveness. Support of long-term prospective cohort studies of which intervention research is a substantial component. Preference of research on engineering intervention strategies when feasible but consideration of administrative and personal or behavioral intervention research when appropriate. Partnerships with production equipment and personal protective equipment manufacturers throughout the process to assist in identifying good candidates for modification and to facilitate testing and deployment of new control technologies.
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Agriculture, Forestry, and Fishing Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health Intervention effectiveness research conducted according to scientific standards. Ensuring that detailed results are disseminated quickly and effectively so that all stakeholders are aware of both successful and unsuccessful intervention strategies. High visibility at all levels in each of the industries and active engagement in community-based participatory programs to deploy effective interventions and disseminate information. Evaluation mechanisms to measure the effectiveness of different strategies for implementing controls and transferring information. A group devoted to evaluating policy development and potential effects on implementation of control strategies for reducing injury and illness in AFF industries. Extensive involvement in research to characterize and identify the best strategies for implementing new control approaches. Development and use of objective measures for assessing the cost-effective distribution and acceptance of control strategies. Coordination and sharing of activities and results across all intramural and extramural research groups and external partners to avoid duplication of efforts and to ensure dissemination of effective strategies. Established effective national networks for rapid dissemination of relevant intervention strategies to users. Readily available results of all intervention research to anyone interested and in a standardized format that allows for quick determination of the relevance and likely effectiveness of a given strategy for another application. Health Services Research and Training The ideal AFF Program would fully describe access to occupational health services for each AFF industry in all regions and for all subpopulations. All important barriers to obtaining such services would be identified and characterized. The program would then use strategies that allow effective delivery of occupational healthcare services to all populations at risk in each industry. When feasible, health promotion and preventive health services would also be offered. The workplace is the primary location at which those services are delivered to many workers, and this justifies the allocation of occupational health resources to meet general wellness needs. A special effort will be required to integrate health services research into the NIOSH agenda. Health services research is central to the NIOSH agenda and would be conducted in both intramural and extramural settings. A substantial propor-
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Agriculture, Forestry, and Fishing Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health tion of resources would be devoted to extramural, competitive grant programs that complement intramural research. Approaches may be specific to industries, occupations, regions, and workforce demographics. Each of the three sectors—agriculture, forestry, and fishing—would receive resources for health services research in an equitable way that is proportionate to injuries and illnesses affecting their worker populations. An effort would be made to nurture the careers of young investigators engaged in occupational health services research. Training programs for occupational safety and health students and practitioners pertinent to all aspects of occupational health relevant to AFF would be further developed, including training for subspecialist physicians with expertise in areas such as pulmonary disease and allergies. The existing NIOSH training of rural nurses with occupational expertise would be expanded. Barriers to completing this work include the historic difficulties encountered when attempting to insert material on occupational and environmental health relevant to all aspects of AFF into the curriculum for health professions students. Existing programs would be reviewed for the relevance of their content and approach. Monetary support of training programs would be offered to fill a gap left by waning institutional support of such programs. The ideal AFF Program would seek new ways to reach worker populations with preventive services and information. The possibilities include partnerships with workers’ compensation insurance carriers to improve characterization of the incidence of illness and injury in the AFF industries and to quantify and control costs. The AFF Program could also work with WC carriers to develop and implement strategies for reaching workers with training materials to increase their awareness of key health and safety topics and to offer incentives for reduction in occupational illness and injury. Incentive-based programs carry the possible danger that workers may be discouraged from reporting injuries or illnesses, but new research is needed to more fully document the impact of such programs. To implement such a program, WC insurance companies would need the cooperation of employers that purchase their insurance, because insurance companies ordinarily do not have direct access to workers unless a claim is filed. NIOSH could play a key role in facilitating such relationships by preparing educational materials and interpreting injury and illness data. Knowledge Diffusion and Technology Transfer For research and technological development to be effective, people at risk of disease or injury would need to apply the information that results from such research and technological development. Knowledge diffusion makes it possible for new information to be shared beyond the narrow confines of researchers. AFF workers can be difficult to reach because they do not work in well-defined settings
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Agriculture, Forestry, and Fishing Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health and often are not native English speakers. New approaches need to be developed to reach such disparate groups. In some instances, research is needed to develop new approaches and to evaluate their effectiveness and efficiency in reaching the at-risk population. That would be a critical activity in the ideal AFF Program. Technology transfer refers to the application of new approaches that can reach at-risk working populations. There are opportunities to develop highly technical approaches to reducing illnesses and injuries among AFF workers, but these approaches would need to be useful in extreme work conditions with highly variable temperatures and weather conditions and with minimal disruption of work productivity. Field testing of new equipment and approaches is essential in an ideal AFF Program because the work environments of farmers, hired farm workers, loggers, and fishermen are substantially different from those in manufacturing and other work settings. Public Policy and Regulatory Advice As the research arm in occupational safety and health, the ideal AFF Program would offer independent, scientifically sound advice to inform public policy and assist regulatory agencies in protecting AFF worker populations. Research would include retrospective cohort studies that aid decisionmaking and inform regulatory activities to reduce workplace injury and illness. In Appendix F, the committee provides detailed information about federal and state policies and regulations that directly affect AFF workers. Program Evaluation Initiatives Effective periodic evaluation throughout the NIOSH process as indicated in the logic model is crucial. All aspects of the AFF Program—including activities, outputs, and outcomes—need to be evaluated for relevance and impact. Assessment of the impact of such programs and use of the assessment results in priority-setting are essential. For such assessment to be useful, the program needs both clear and repeatable processes for tracking and collecting information on fatalities and injuries. Robust surveillance data constitute an absolute foundation for quantitatively measuring program impacts. In some cases, research initiatives would be evaluated on an ongoing basis by third-party professionals who contract directly with the AFF Program. Whenever practical, interventions developed by the AFF Program would rely on the “gold standard” of evaluation: comparing workers exposed to the hazard with all or randomly selected non-exposed workers. An essential element of evaluation is transparency, which can be enhanced by holding local, regional, or national con-
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Agriculture, Forestry, and Fishing Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health ferences at which information derived from basic and applied research and from surveillance is exposed to public scrutiny. In addition to internal and external program reviews, overall program evaluations can provide a high level of evaluation of the overall NIOSH program, with examples including recent National Academies studies (IOM and NRC, 2006; NRC and IOM, 2007). Such reviews are essential to help NIOSH maximize its impact on safety and health.