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

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3 Targeting of New Research and Identification of Emerging Research Needs T he second part of the committee’s charge was to perform an assessment of the Traumatic Injury (TI) Research Program’s effectiveness in targeting new research areas and identifying emerging issues most relevant to future improvements in workplace protection. The first part of this chapter outlines the processes that the National Institute for Occupation Safety and Health (NIOSH) and the TI Research Program use for research project planning and resource alloca- tion as well as identification of emerging issues relevant to the NIOSH mission. The second part of this chapter is the committee’s evaluation of these processes. The chapter concludes with the committee’s evaluation of the TI Research Program’s draft “strategic goals for the future.” This evaluation includes comments on the relevance of the proposed strategic goals, identifies gaps in the proposed research and emerging issues, and makes other suggestions about how the goals can be strengthened in later iterations. THE TI RESEARCH PROGRAM’S PROCESS FOR TARGETING NEW RESEARCH AND IDENTIFYING EMERGING RESEARCH NEEDS The following descriptions of the TI Research Program’s process for research project planning and resource allocation and identification of emerging research needs come primarily from the evidence package provided to the committee. The majority of the information relates to intramural research, because the commit- tee did not have available much information on how NIOSH or the TI Research Program develops research priorities for extramural research. 111 

112 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 Research Project Planning and Resource Allocation NIOSH TI research project planning takes place at the research division level and at the institute level. At the division level, Division of Safety Research (DSR) staff propose research projects within the context of program drivers, which may include surveillance findings on injury incidence and severity, worker groups with the greatest numbers and risk of death or injury, congressional mandates, stakeholder input, or research needs outlined in the 1998 National Occupational Research Agenda (NORA)-TI team white paper (NIOSH, 1998). DSR leadership—with input from staff—rates and ranks new project concepts based on project need, soundness of approach or methods, and expected impact (NIOSH, 2007a, p. 43). Concepts that rank highest are approved based on funding availability. Staff may then develop research pro- tocols within the approved concept areas. Research protocols are peer-reviewed internally, and may also be presented at public meetings for stakeholder input and to assess the interest in and potential impact of the research. When research projects end, funding returns to a pool for competition for new project concepts proposed by DSR staff (NIOSH, 2007a, p. 43). At the institute level, NIOSH researchers, on an annual basis, have the oppor- tunity to compete for NORA funds set aside for intramural research. Competition for these funds is institute-wide, although the NIOSH director may sometimes call for focus in a specific area. The director makes final project funding decisions us- ing scores from an external peer review and available funding. When projects are completed, funding returns to the NORA pool for renewed intramural competition (NIOSH, 2007a, p. 43). According to DSR leadership, most current TI Research Program projects are funded through the institute-wide NORA funding competition. DSR “base” funds (annual division or lab allocation) have diminished and are now used primarily for ongoing surveillance and field investigation programs, as well as congressionally mandated projects (NIOSH, 2007a, p. 43). Funds left over from the few DSR- specific funded projects that end each year are used to cover costs to the Centers for Disease Control and Prevention, which have increased in recent years, as well as annual cost-of-living increases. There has not been competition for new projects with DSR base funds for the past 3 years. Extramural researchers may request NIOSH funding for TI research through NIOSH general program announcements, targeted requests for applications (RFAs) developed by the TI Research Program aimed at filling specific program gaps, and  This description does not include project planning and resource allocation for mining TI research, which is managed by the separate NIOSH Mining Safety and Health Research Program.  Personal communication from N. Stout. 

Targeting of N e w R e s e a rc h 113 cooperative agreements. As with the institute-wide competition for NORA funds, extramural applicants submit proposals that are externally peer-reviewed and scored (NIOSH, 2007a, p. 43). As part of a process of continued project assessment and adjustment, quarterly progress reports for each intramural TI Research Program project are distributed among staff for information sharing, progress assessment, and input. There is also an annual midyear review of programs and projects. Projects found not to be meeting anticipated progress or value may be discontinued. These assessments have been important in ensuring the sustained quality and relevance of TI Research Program’s work (NIOSH, 2007a, pp. 43-44). NIOSH is currently implementing a matrix organizational process for coor- dinating research projects across programs and divisions or labs. The goals of this organizational process are to improve internal management and coordination of intramural and extramural research and planning, and to increase research rel- evance and impact. Project administration and management remains a division- level responsibility (NIOSH, 2007a, p. 44). Stakeholder Input The TI Research Program has several means by which it receives input from stakeholders on its research programs. For intramural projects, NIOSH frequently holds a public meeting announced in the Federal Register. Public meetings may be held to discuss proposed research projects that will develop or evaluate products (versus policies or procedures) that have broad stakeholder vested interest and/or are potentially controversial. The TI Research Program also organizes and hosts periodic National Occupational Injury Research Symposia (NOIRS), which bring together researchers from a broad range of disciplines to discuss research in prog- ress and to form research and prevention partnerships. Workers, advocates, and other nonresearch groups may also attend and have an opportunity to provide input regarding TI research needs. The symposia is one means of implementing NORA for traumatic injuries. The TI Research Program has held four NOIRS since 1997 (the most recent in October 2008). At the inception of the four TI research programs currently directed by congressional initiatives and mandates (agricultural injuries among children, workplace violence, firefighter safety, and workers in Alaska’s high-risk industries), NIOSH held stakeholder meetings to get input on possible research directions within these areas. TI Research Program staff also receive input through memberships with standards-setting and profes- sional association committees (NIOSH, 2007a, p. 44) and the Council of State and  Personal communication from N. Stout. 

114 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 Territorial Epidemiologists. In addition to facilitating research project planning, engagement with stakeholders is an important means of identifying emerging TI research needs. Identification of Emerging Research Needs The TI Research Program uses surveillance data on fatal and nonfatal injuries— primarily from the Bureau of Labor Statistics (BLS) surveillance systems—to identify emerging research needs. The program also has real-time access to data on injuries reported at hospital emergency departments through the National Elec- tronic Injury Surveillance System (NEISS); data on fatal injuries in selected states through the NIOSH Fatality Assessment and Control Evaluation (FACE) Program, which allow for quicker detection of injury clusters and spikes (NIOSH, 2007a, p. 46); and sentinel fatalities that identify previously unrecognized hazards. Identification of emerging research needs also comes from TI Research Program engagement with stakeholders and partners. The series of NOIRS organized by the TI Research Program provide staff the opportunity to learn of emerging issues in traumatic injury research as well as adapt partnerships to address them (NIOSH, 2007a, p. 46). Identification of emerging problem areas in workplace trauma is one of the specific agenda items addressed at each of the NOIRS (NIOSH, 2007a,b). The NORA process and the relationships with stakeholders that result from it are also an important means of identifying emerging issues. In NORA I there was a committee that specifically addressed TI research needs; in the current NORA II process, industry-sector councils have been formed to address sector-­specific re- search needs. Traumatic injuries are addressed by each of these councils. The evidence package also describes features of the TI Research Program that facilitate response to emerging issues. These include the annual realignment of research priorities through the TI Research Program planning process, review of surveillance data and connectivity with stakeholders, and a flexible fatality inves- tigation (FACE) program that allows for changes in the types of fatal incidents that are investigated (NIOSH, 2007a, p. 46). Notably absent is any reference to the Occupational Safety and Health (OSHA) regulatory agenda as input to program planning. COMMITTEE ASSESSMENT OF THE TI RESEARCH PROGRAM’S Process FOR TARGETING NEW RESEARCH AND IDENTIFYING EMERGING RESEARCH NEEDS As discussed in more detail in Chapter 4, the committee is sensitive to the need for the TI Research Program to choose its research activities carefully to make the best use of limited resources. 

Targeting of N e w R e s e a rc h 115 Although the committee recognizes that both the severity and the magnitude of injury are important to consider when setting TI research priorities, it is concerned that the balance of focus between fatal and nonfatal injuries is either not evident or not optimal. Based on information provided in the evidence package, it is appar- ent that occupational fatality surveillance data have been an important program driver. Nonfatal occupational injuries far outnumber fatal injuries, and risk fac- tors for fatal and nonfatal injuries are not necessarily the same. As was discussed in Chapter 2, while a focus on fatalities is reasonable in light of limited resources, it leaves a very substantial gap with respect to nonfatal injuries. The TI Research Program should be explicit about its consideration of fatal versus nonfatal data and provide a clear rationale when proposing and approving projects. Additional surveillance and surveillance research are needed to improve the characterization of nonfatal injuries (see Chapter 4 for a discussion). The committee sees coordination of intramural and extramural research activi- ties as essential to the TI Research Program’s project planning process, especially given its limited resources and the importance of injury prevention and control research (see Chapter 4 for a discussion). Although the TI Research Program has opportunities for sharing of research ideas through several means—including NOIRS and staff participation on professional committees—the extent to which in- tramural researchers and extramural researchers are aware of each other’s research and possible collaboration opportunities is not clear from the evidence package. Without some coordination of research activities, researchers may miss opportuni- ties to access expertise as well as avenues for dissemination of research findings. Stakeholder input into the TI Research Program’s project planning and identi- fication of emerging issues is important for ensuring the relevance of the research ultimately pursued. The committee sees NOIRS as important mechanisms for the TI Research Program to implement NORA and to foster the relevance of its research though dissemination. Alternative means of gathering external input may be necessary in years when NOIRS are not held. Research program external review sometimes includes a public meeting announced in the Federal Register. Additional strategies for gaining input from nonresearch groups—such as employers and employees—for both research project planning and identification of emerging issues should be considered as well. Because the FACE Program collects real-time data on fatal occupational inju- ries, it allows for timely identification of previously unrecognized hazards. FACE investigations provide in-depth information about factors leading to fatal incidents that is not available elsewhere. This information is useful not only in generating hypotheses for future research, but also in developing recommendations for imme- diate prevention measures. FACE reports, which are based on these investigations and include recommendations to prevent similar incidents, are an important ve- hicle for reaching employers, workers, and product manufacturers with prevention 

116 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 messages. Investigations conducted by the NIOSH FACE Program and state-based FACE programs have facilitated the development of numerous interventions, in- cluding changes in workplace policies and practice, as well as equipment design. In conjunction with population-based fatality statistics, FACE data can assist NIOSH and the TI Research Program with strategic selection of problems upon which to focus future research. COMMITTEE REVIEW OF the TI RESEARCH PROGRAM’s STRATEGIC GOALS FOR THE FUTURE Following the 2005 implementation of a matrix management structure to coordinate cross-institute programmatic activities, a NIOSH TI steering com- mittee was formed to develop strategic goals and outcome measures for NIOSH TI research. The steering committee, with input from staff, developed a list of TI strategic goals for the future. The evaluation committee was informed that the list of goals is evolving as NIOSH considers external input. In the evidence package, the evaluation committee was invited to comment on the TI Research Program’s strategic plan to help “maximize the relevance, quality and impact of the NIOSH TI Research Program” (NIOSH, 2007d, p. 195). The TI Research Program’s five strategic goals for the future are to (1) reduce fall injuries in the workplace; (2) reduce occupational injuries and deaths due to motor vehicles; (3) reduce occupational injuries and deaths due to workplace vio- lence; (4) reduce occupational injuries and deaths due to machines and industrial vehicles; and (5) reduce occupational injuries and deaths among high-risk and vulnerable worker groups. Within each of the five strategic goals are three or four subgoals that generally identify types of injuries, worker populations, industries, and workplace exposures on which to focus. At the next level are intermediate goals for achieving goal and subgoal objectives (see Box 3-1 for the goals and subgoals. The complete list with intermediate goals can be found in Appendix D). The following section outlines the committee’s review of the TI Research Program’s proposed research within the five strategic goal areas. Based on member expertise, the committee identified areas of research that warrant attention in the future. Some of these are described in the context of the review of the strategic goals, and some are described in a subsequent section. Given limited staffing and budget resources, it is not expected that the TI Research Program will pursue all of the proposed research areas, but rather that it will take them into consideration.  The numbering of the goals here is consistent with the numbering of the goals as presented in the evidence package prepared by NIOSH for the committee. Numbering is not a ranking of goals by research priority. 

Targeting of N e w R e s e a rc h 117 BOX 3-1 TI Research Program Strategic Goals for the Future 1. Reduce fall injuries in the workplace 1.1. Reduce fall-related fatalities and injuries in the construction industry 1.2. Reduce fall-related injuries in the health services industry 1.3. Reduce fall-related injuries in the wholesale and retail trade industry 1.4.  educe fall-related injuries through research on biosciences underlying human fall R initiation, fall dynamics, fall termination, and control measures 2. Reduce occupational injuries and deaths due to motor vehicles 2.1.  educe motor vehicle-related incidents in the transportation, warehousing, and R utilities (TWU) industry sector 2.2.  educe fatal and serious nonfatal injuries to workers in roadway construction R work zones 2.3.  educe injuries and fatalities from motor vehicle incidents, including being struck R by vehicles, among public safety and emergency response workers 2.4.  educe occupational road traffic injuries worldwide R 3. Reduce occupational injuries and deaths due to workplace violence 3.1.  educe workplace violence in the transportation, warehouse, and utilities industries R 3.2.  educe workplace violence among high-risk wholesale and retail trade workers R including grocery stores, gasoline stations, convenience stores, bakeries, and liquor stores 3.3.  dentify risk factors and effective interventions to prevent workplace violence I among high-risk services, healthcare, and social service sector workers such as eating and drinking establishment workers; hotel or motel workers; automotive repair mechanics; teachers; nurses and nursing assistants in general medical, home health care, nursing homes, and psychiatric hospitals; social service workers in job training, residential care, and day care industries; private security workers; and public safety and correctional workers in emergency response tasks (e.g., medical services, police calls, and correctional officer activities) 4. Reduce occupational injuries and deaths due to machines and industrial vehicles 4.1.  educe occupational injuries and deaths due to machines and industrial vehicles in R the agriculture, forestry, and fishing industry, with an emphasis on tractor-related injuries and deaths 4.2.  educe occupational injuries and deaths due to machines and industrial vehicles R in the construction industry 4.3.  educe occupational injuries and deaths due to machines and industrial vehicles R in the manufacturing industry 4.4.  educe occupational injuries and deaths due to machines and industrial vehicles R in the mining industry 5. Reduce occupational injuries and deaths among high-risk and vulnerable worker groups 5.1. Reduce occupational injuries and deaths among young workers 5.2. Reduce occupational injuries and deaths among older workers 5.3.  educe occupational injuries and deaths among high-risk ethnic and minority R workers 5.4. Reduce occupational injuries and deaths among immigrant workers 

118 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 Evaluation Committee’s Assessment of TI Strategic Goals for the Future The committee’s comments on each of the TI Research Program’s five strate- gic goals areas are given below. Overall, the committee finds that the TI Research Program’s strategic goals are focused on major contributors to occupational in- juries and deaths and are sensitive to populations and groups at disproportion- ate risk. Among the strategic goals are several intermediate goals for leveraging partnerships that, if carried out, could help the TI Research Program a great deal in maximizing impact. In certain areas (specifically, in the future goals for motor vehicles), in future iterations of its strategic goals the TI Research Program should work toward focus- ing its efforts on areas that are not researched by other agencies or covered by other agency missions. Future goals should be evaluated and updated regularly. In general, the committee also feels that future modifications to the goals could include better indication of how proposed interventions and partnerships will be evaluated. Strategic Goal 1: Reduce Fall Injuries in the Workplace The TI Research Program strategic goal for fall injuries addresses an important source of fatalities from occupational injuries. The committee finds the planned efforts targeting falls from elevations in the construction industry (intermediate goals 1.1.1 and 1.1.2) to be especially appropriate given the high frequency of fa- talities from falls in that industry. One of the weaknesses of the current program described in Chapter 2 is the lack of formal recognition by the TI Research Program of slips, trips, and falls (STFs) at the same level. The strategic goals also reveal little planned research on same-level STFs for the future. Intermediate goal 1.2.2 is to identify and summarize research on STFs applicable to the health services industry, and same-level falls may be an implicit focus of this goal. Same-level STFs are a major source of work-related mor- bidity. The committee believes it would be relevant for the TI Research Program to make surveillance of same-level STFs among health services and other workers a focus for future research. With respect to STF risk factor and intervention research, one of the major issues continues to be the lack of understanding of tribology for both wet and dry surfaces and the effects of the various polymers used in shoe materials. There is currently no available means of measuring slipperiness as opposed to the various measures of the coefficient of friction. The TI Research Program could initiate progress in this area, perhaps through collaborations with other agencies such as the National Science Foundation, which has a tribology section. One justification for expansion of the falls program to include additional research on STFs at the same level is the increasing number of people working 

Targeting of N e w R e s e a rc h 119 beyond the normal age of retirement who are at higher risk of injury from falls. In a presentation before the committee, the TI Research Program identified an aging workforce as an emerging issue in fall prevention research. There could be crosscut- ting synergies between research on same-level falls and the TI Research Program’s planned goals for reducing occupational injuries and deaths among older workers (see strategic goal 5.2). Strategic Goal 2: Reduce Occupational Injuries and Deaths Due to Motor Vehicles Transportation incidents are consistently the leading cause of fatal occupational injuries. The committee therefore considers it appropriate for the TI Research Pro- gram to continue work in this area where there is a specific occupational context and an opportunity to make a unique contribution. Increased collaborations with the National Highway Traffic Safety Administration (NHTSA) and other Depart- ment of Transportation agencies will be key to increasing the profile of the work- relatedness of motor-vehicle injuries. Strategic subgoals 2.2 and 2.3 for the prevention of motor vehicle injuries in roadway construction work zones and among public safety and emergency response workers address important contributors to occupational motor vehicle- related traumatic injury and death and are relevant for the TI Research Program. In the area of construction work zones, the committee in particular supports the planned continued efforts to evaluate the proximity warning systems (PWS) and internal traffic control plan (ITCP) interventions for use on road construction sites (intermediate goals 2.2.2 and 2.2.3). The committee also supports the planned continued research on some motor vehicle-related causes of occupational injuries among emergency responders (subgoal 2.3) and the promulgation of information on safety restraints. Given its limited resources and focus on occupational injuries, the committee found subgoal 2.1—to reduce motor-vehicle-related incidents in the transporta- tion, warehousing, and utilities (TWU) industry sector—to be rather broad for the TI Research Program to pursue. The committee sees this goal and its intermediate goals 2.1.1, 2.1.3, and 2.1.4 as being more appropriately addressed by an organiza- tion such as NHTSA, which has more resources and a focus on general highway safety rather than occupational safety. As discussed below, however, the committee does believe that the TI Research Program could contribute to research and inter- vention on the occupational aspects of short-haul trucking. Subgoal 2.4—to reduce occupational road traffic injuries worldwide—is a strategic goal of the NIOSH Global Collaborations Program in TWU. Efforts of this program are intended to benefit both U.S. workers and workers globally 

120 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 through international partnerships and information sharing (NIOSH, 2008). The committee finds this subgoal relevant for the TI Research Program. Indeed, the United States has much to learn from other countries in the area of occupational safety and health. In the area of motor vehicle research in particular, as stated else- where, NIOSH should be quite focused and judicious in the allocation of limited resources.  International research then should promote benchmarking (learning from those with better practices) and the focused motor vehicle goals established (e.g., work zone safety). Gaps in motor vehicle injury research identified by the committee include taxi driving, short-haul trucking, day delivery drivers, parking lot occupational driving, and intrastate driving. Focusing on taxis should offer crosscutting synergies within NIOSH; taxi driving is a hazardous occupation because of both workplace violence and the occupational driving itself. Taxi driving creates risk not only for the drivers, but also for the occupants of the taxi, pedestrians, and occupants of other vehicles. While much research is done on long-haul trucking safety by agencies such as NHTSA, traumatic injuries associated with short-haul trucking (defined as trips of less than 50 miles) are underserved in terms of research and intervention. Short- haul trucking accounts for the majority of the trucking industry (Hanowski et al., 2000). In addition, there may be an opportunity to address the nondriving aspects commonly involved in short-haul trucking such as lifting and handling that are not as common for long-haul trucking. Day delivery driving is a concern because of both the driving aspects and package delivery aspects of the job (Hira, 2007). Slips and falls, lower back injury, and sprains and strains are particular concerns. Other areas of potential opportunity for high-impact research include parking lot and rest area traumatic injuries related to short-haul trucking and intrastate driving. Strategic Goal 3: Reduce Occupational Injuries and Deaths Due to Workplace Violence The activities outlined in the future goals for workplace violence demonstrate good research program transitioning—beginning with surveillance and identifica- tion of risk factors—and moving into design and implementation of interventions where needed. The committee finds these goals to be a good model for how to build on previous achievements in the other goal areas. Workplace violence goals also appear to be well aligned with NORA II, with objectives focused on research in the transportation, healthcare, service, and retail sectors. Although its goals are generally directed appropriately toward understanding the most high-risk situations, the TI Research Program might consider focusing in subgoal 3.2 on workplace violence against retail workers only, rather than against both retail and wholesale workers, because more violence occurs in retail than in 

Targeting of N e w R e s e a rc h 121 other workplace environments. The committee finds intermediate goals for the development of partnerships with organizations, associations, police departments, and employers to be appropriate for maximizing research relevance and impact, but a corresponding evaluation component is needed to assess the effectiveness of partnerships. Worker-on-worker (or Type III) workplace violence and domestic violence in the workplace (which is included in Type IV) appear to be absent from the strate- gic goals, although they may be included implicitly. The committee finds study of worker-on-worker violence (e.g., bullying) and domestic violence in the workplace to be important areas of research for NIOSH, but they may be best addressed within the NIOSH Work Organization and Stress-Related Disorders Program, rather than the TI Research Program. Strategic Goal 4: Reduce Occupational Injuries and Deaths Due to Machines and Industrial Vehicles This strategic goal includes plans to complete testing and market develop- ment of the auto-deploying rollover protective structure (AutoROPS) for use in low-clearance farming and the cost-effective ROPS (CROPS) for adoption by manufacturers (see intermediate subgoals 4.1.1-4.1.3). These subgoals represent a continuation of previous efforts by the TI Research Program to address barri- ers to the use of ROPS on tractors by farm workers. The work of the TI Research Program on ROPS is to be commended, and the committee supports its future goals for AutoROPS and CROPS. However, studies (Hallman, 2005; Spielholz et al., 2006) indicate that retrofitting of older tractors is occurring at a slower than optimal pace and that, in addition to cost, a “hassle factor” has been an obstacle to retrofitting even when there is a financial incentive for doing so. The TI Research Program could devote more resources toward technology adoption research to facilitate faster farm worker adoption of this important technology. In addition to continued work on AutoROPS and CROPS, the strategic goals include plans to develop and/or evaluate several other technologies to prevent machine-related injuries, such as the machine emergency-stop (or “e-stop”) system for use on commercial fishing vessel machinery (intermediate goal 4.1.6) and a   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). 

122 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 proximity warning system for use on road construction equipment (intermediate goal 4.2.2). If widely adopted, these technologies are likely to have a great impact on reducing machine-related injuries. Evaluation of the protective technologies themselves, as well as the barriers to their adoption, will be important for success- ful implementation. A gap in the TI Research Program’s planned future research on machine-related injuries is the prevention of injuries resulting from devices used for landscaping, such as riding and zero-turn lawn mowers, mechanical hedge trimmers, cultiva- tors, and others. Landscaping and horticultural work has been identified as one of the most hazardous industries, and machinery is one of the sources of injury within that industry. Strategic Goal 5: Reduce Occupational Injuries and Deaths Among High-Risk and Vulnerable Worker Groups The U.S. workforce is aging and becoming increasingly racially and ethni- cally diverse. Recognizing these changing demographics of the U.S. workforce, the committee supports the addition of research on older workers and immigrant and minority workers to the TI Research Program’s research goals for the future. The committee also supports the continuation of research on youth, because this group continues to have unique research needs. The TI Research Program should consider expanding its current focus on workers younger than age 18 to the 18-24- year-old age group, which has the highest nonfatal occupational injury rate. The next decade will witness an influx of new workers in this age range as the children of the baby boomer generation enter the workforce in peak numbers. (See section on The Changing Nature of Work in Chapter 4 of this report.) The strategic goals for high-risk and vulnerable groups include improved sur- veillance (intermediate goals 5.1.1, 5.2.1, 5.3.1, 5.4.1). Innovative approaches will be necessary to document the experience of vulnerable worker groups who are not well captured in the conventional occupational health data sources. The strategic goals (intermediate goals 5.2.2, 5.3.2, 5.4.2) include identification of risk factors for injury and death among older workers and among minority and immigrant workers. The committee feels there is also a continued need for risk factor research on young workers. It will be important to extend risk factor research on vulner- able workers to include the study of informal and formal workplace policies and workplace norms, and alternative work arrangements, as well as individual charac- teristics that may contribute to disparate risks. Research on individual worker char- acteristics should include the exploration of social and cultural as well as the more commonly recognized language barriers. In its review of the TI Research Program’s current goals the committee saw little evidence that research on vulnerable worker 

Targeting of N e w R e s e a rc h 123 groups had been a high priority, and program efforts addressing immigrant and minority workers seemed to focus predominately on language barriers. The TI Research Program strategic goals include a specific intermediate goal (5.2.3) to evaluate intervention strategies to prevent older worker injuries and deaths. The committee sees a need for evaluation of intervention strategies for preventing injuries and deaths among youth, minority workers, and immigrant workers as well. Community-based participatory approaches should be included. Collaboration with the NIOSH Occupational Health Disparities program will be important to improve research capacity in this area. While the committee sup- ports plans for partnerships (intermediate subgoals 5.2.4, 5.3.3, 5.3.4, and 5.4.3) with government agencies, safety groups, and other organizations, the TI Research Program might consider adding an evaluation component to measure how well the partnerships are working. Two populations that are not specified in the TI Research Program’s strategic goals and for which research is currently lacking are workers with developmental or physical disabilities and workers in nontraditional work arrangements (e.g., contract workers, day laborers). Little research has been performed either to track injuries among people with disabilities or to identify their unique risk factors for injury. Intervention research is needed for workers in nontraditional work ar- rangements that may involve highly hazardous work. Because of lack of oversight, inadequate training, lack of access to health and safety resources, and other factors, these workers may not be afforded the same protections as permanent workers. One area of current TI Research Program research that is not reflected in the strategic goals for the future is research on acute back injuries. According to TI Research Program staff, work on acute back injury will be moved out of the TI Re- search Program and into the NIOSH Musculoskeletal Disorders Research Program. The committee supports NIOSH’s continuation of research on back injuries, which continue to be among the most serious and costly occupational health problems. The committee learned from senior TI Research Program staff that while there is no longer an Alaska-specific goal in the proposed goals for the future, the TI Re- search Program intends that the work of the Alaska Field Station (recently renamed the Alaska Pacific Regional Office) will continue to contribute to the cause-specific goals of the TI strategic plan. Intermediate goals 4.1.4-4.1.8 for machinery are a continuation of some of the traumatic injury research being performed under the current goal to reduce injuries and fatalities among workers in Alaska’s fishing and logging industries. The committee finds that NIOSH’s research in Alaska to date  Personal communication from N. Stout.  Personal communication from N. Stout. 

124 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 has been impressive and can serve as a model for moving research to practice in other states and in other goal areas. The TI Research Program will continue research on emergency responders within its proposed strategic goals for motor vehicle-related injuries (subgoal 2.3). The committee supports risk factor and intervention research for this population, as planned in intermediate goals 2.3.1 and 2.3.2. Through past investigations of firefighter and emergency medical services (EMS) worker deaths in ambulance crashes, the TI Research Program has demonstrated a need for better passenger protective equipment (NIOSH, 2007c, p. 150) and has been investigating engineer- ing interventions. Plans to develop and promulgate information on restraints to firefighter and EMS workers (intermediate goal 2.3.3) are an appropriate extension of this research. Other Gaps in Traumatic Injury Research In addition to gaps in research noted within the context of the five strategic goals, the committee identified other priority research areas that the TI Research Program could pursue in the future. Without attempting to convey a complete roster of additional research needs, the committee offers five illustrative areas that warrant attention in the future: 1. Organizational culture and adoption of safety measures. Successful trans- lation of safety research into practice is dependent upon the culture— including the attitudes, experiences, core beliefs, and values—of a workplace. Instituting measures to protect worker safety and health can be difficult when such measures are inconsistent with elements of an organization’s culture. In a workplace where there is high emphasis on short-term production (rather than longer-term productivity), for example, employees may be less likely to make use of a safety measure they feel might slow them down, because of the competing demand to produce more in a given amount of time. While culture is often acknowledged as an important factor inside and outside NIOSH, translation and dissemination of research into the many elements of organizational culture that facilitate safety prevention and inhibit employer adoption of safety measures are needed. 2. Cost of injuries. When safety measures are being considered by an em- ployer, they often must compete with carefully detailed cases for other employer investments (such as equipment and facilities) that are usually supported by a statement of the cost of implementation and a predic- tion of improvements in productivity or reduction of labor measured in 

Targeting of N e w R e s e a rc h 125 dollars. These estimates allow a rational, benefit-cost ration-based deci- sion to be made by the employer. Comparable benefit-cost estimates for adoption of safety measures are often not possible. The hidden indirect costs that an employer might save by adopting a safety measure, such as the costs associated with employee time away from work due to an injury or the costs of training new employees, can be difficult to esti- mate. There is a need for research to develop both an agreed method of calculating benefits for adoption of safety measures and an updated publication of the costs of various injuries. 3. Policy evaluation research. The committee sees a role for the TI Re- search Program in the evaluation of both public and company policies that impact the occurrence of occupational injuries. For example, as an extension of plans to provide the empirical data to guide the develop- ment and enforcement of child labor laws (intermediate goal 5.1.3), the TI Research Program could also be involved in the evaluation of such laws if they are enacted. Other important policy areas to evaluate might include the effectiveness of state requirements for maintaining workplace safety programs; workplace health and safety committees required by state laws or collective bargaining agreements; and cost of compliance or noncompliance with specific OSHA regulations (e.g., fall protection, trenching, ladders). 4. Small- to medium-sized enterprises (SMEs). SMEs seem to be particu- larly vulnerable to the perceived trade-off between safety and produc- tivity and other cultural issues mentioned earlier. In addition, there are many workers in potentially dangerous occupations that work for small companies and contractors that are unlicensed, not certified, and have no safety programs. In many of these settings there is a large representation of immigrants, minorities, and other vulnerable groups. Surveillance research is needed to determine the extent and types of injuries that occur in SMEs, particularly nonfatal injuries for which reporting has been a problem. Findings from such research would help provide the basis for determination of whether and how injuries that occur in SMEs differ from those that occur in larger enterprises and could inform SME-targeted risk factor and cost-sensitive intervention research as well as evidence-based best practices for SMEs that seek to reduce their work-related risks and costs. It has been well documented that small businesses face special challenges in complying with safety regulations and safe work practices. These challenges include lack of access to information, lack of access to expertise, and lack of capital for investment in safety. Special attention is needed to research the 

126 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 barriers to the adoption of safety measures by small businesses, and the incentives and resources needed to overcome these barriers. 5. Surveillance. The success of the TI Research Program depends on a robust surveillance system. As indicated in Chapter 2 and as will be discussed in Chapter 4, the committee believes that NIOSH would benefit from an overall strategy regarding surveillance research and implementation. Improving the surveillance system and surveillance research is of sufficient importance to warrant inclusion as a separate strategic goal for the TI Research Program. Stakeholder Comment As part of its evaluation, the committee sought the input of stakeholders on the relevance and impact of the TI Research Program’s current research portfolio. Responses to this request included several suggestions for additional research. A summary of these suggestions, along with an outline of the stakeholder comment request process, can be found in Appendix B of this report. REFERENCES Hallman, E. M. 2005. ROPS retrofitting: Measuring effectiveness of incentives and uncovering inher- ent barriers to success. Journal of Agricultural Safety and Health 11(1):75-84. Hanowski, R. J., W. W. Wierwille, S. A. Garness, T. A. Dingus, R. R. Knipling, and R. J. Carroll. 2000. A field evaluation of safety issues in local/short haul trucking. In Proceedings of the XIVth Trien- nial Congress of the International Ergonomics Association and 44th Annual Meeting of the Human Factors and Ergonomics Society, Santa Monica, CA. Hira, N. A. 2007. The making of a UPS driver. Fortune, November 7. NIOSH (National Institute for Occupational Safety and Health). 1998. NORA: Traumatic occupational injury research needs and priorities. Washington, DC: HHS. NIOSH. 2006. NIOSH Awards Funding to Ag Research Centers for Initiative to Reduce Tractor Deaths, Injuries. NIOSH Update. March 21, 2006. http://www.cdc.gov/niosh/updates/upd-03- 21-06.html (accessed July 24, 2008). NIOSH. 2007a (unpublished). Overview of the TI Research Program. In the evidence package provided to the Committee to Review the NIOSH TI Research Program. NIOSH. NIOSH. 2007b. 2008 national occupational injury research symposium. http://www.cdc.gov/niosh/ noirs/2008/about2008.html (accessed November 20, 2007). NIOSH. 2007c (unpublished). Current TI research goals and sub goals: Reduce injuries and fatalities to emergency responders. In the evidence package provided to the Committee to Review the NIOSH TI Research Program. NIOSH. NIOSH. 2007d (unpublished). TI strategic goals for the future. NIOSH. NIOSH. 2008. NIOSH program portfolio: Global collaborations in transportation, warehousing and utilities. http://www.cdc.gov/niosh/programs/twu/global/ (accessed July 24, 2008). Spielholz, P., T. Sjostrom, R. E. Clark, and D. A. Adams. 2006. A survey of tractors and rollover protec- tive structures in Washington State. Journal of Agricultural Safety and Health 12(4):325-333.