NORA Symposium 2011:
The National Occupational Research Agenda (NORA) Liaison Committee in cooperation with the National Institute for Occupational Safety and Health presented two awards at the NORA Symposium held in Cincinnati, Ohio, July 11-12, 2011.
The NORA Innovative Research Award for Worker Health and Safety
The NORA Innovative Research Award for Worker Health and Safety honors innovative and creative occupational health and safety research in a NORA priority area. The purposes of the award are to recognize the development of or encourage continued work with a new approach to prevent and/or reduce occupational illness and injuries. Candidates may be affiliated with a university, industry, government agency, labor union, or a private organization.
The 2011 Award recipient is Effectiveness of Training and Reinforcement on Hearing Protective Devices (HPD) Use Among Construction Workers
Noise induced hearing loss (NIHL) claims in the US are estimated to cost hundreds of millions to billions of dollars annually. Workers suffering from NIHL are denied the ability to converse normally with others and are at increased risk of traumatic injury, depression, social isolation, and many other adverse outcomes. Construction workers are at particularly high risk of exposure to damaging levels of noise. However, due to the inherently dangerous nature of construction work, chronic health hazards such as noise have historically received little attention.
To evaluate the effectiveness of different strategies to increase use of hearing protection devices (HPDs) and prevent NIHL among construction workers, a large four-year study was designed and implemented at eight construction sites near Seattle, WA. The aim of the study was to assess the effectiveness of a three-component intervention in motivating construction workers to effectively wear HPDs during periods of high noise exposure.
The study consisted of three interventions: 1) a one-hour long hearing conservation training; 2) use of an innovative new noise level indicator (NLI), and; 3) reinforcement tool-box trainings (TB). The hearing conservation training, which was guided by a revised version of Pender’s Health Promotion Model (HPM), addressed common barriers to HPD use, and met OSHA training requirements. The training incorporated several "hands-on" demonstrations, as well as teach-back elements for trainees to respond to questions and real-life experiences. The training was designed to allow peer trainers, or trainers trained by an expert, to be able to give the training as effectively as an expert. The NLI was a prototype, smaller than a cell phone, which provided real-time noise levels to construction workers by flashing different colored lights and vibrating at noise levels at or above 85 dBA. The prototype NLI was developed in conjunction with a manufacturer (Quest Technologies, Inc), and designed it to be worn on workers’ lapels for maximum visibility. Five-minute long TB trainings were given every other week for two months (four TB trainings total per worker) following the hearing conservation training. Each of the TB trainings covered a single key topic from the hearing conservation training. Intervention activities on each site started with the one-time hearing conservation training but lasted two months with the additional NLI intervention (for some subjects) and TB events (for some sites).
All participants across the eight participating sites received the one-hour hearing conservation training. Four sites received the bi-weekly TB training. Workers at all eight sites were randomized into two groups, those who received NLI and those who did not. In total, there were four intervention groups: those who received training only, those who received training and NLI, those who received training and TB, and those who received training, NLI and TB.
The primary focus of the intervention evaluation was assessment of workers’ full-shift noise exposures using data-logging dosimeters with simultaneous completion of a task card reporting HPD use. The percent of time during a shift in which 2 average LEQ levels (measured according to the NIOSH Recommended Exposure Limit for noise) exceeded 85 dBA was calculated using a combination of dosimetry data and HPD use data from the associated task card. Workers completed dosimetry and reported HPD use on three different shifts: one prior to intervention (the baseline period), one after all intervention activities were completed (two months after training), and a final one four months post-intervention. A second, questionnaire-based HPD use measure was collected at the same time points, as was information about workers’ perceptions of site safety climate.
Two hundred and seventy-one construction workers were enrolled from nine trades into the study. Full-shift exposures routinely exceeded the NIOSH REL of 85 dBA. The mean full-shift LEQ level prior to intervention was 89 ± 5 dBA, with an average of 40±20% of time in each shift spent above 85 dBA. Average levels dropped slightly at the two and four month follow-ups, though both were still above 85 dBA (88±5 dBA and 87±5 dBA, respectively, and about 33% of each shift spent over 85 dBA on average).
The study found that self-reported HPD use was more accurate from task cards than from surveys; HPD use was typically overstated via survey. Among the 176 workers who completed exposure assessments at baseline, at the end of the two month intervention period, and at the 4-month follow-up, the percent of time HPDs were used in high noise increased from 35% pre-intervention to almost 50% two months post-intervention. At the four month follow-up, HPD use was just over 40%. A statistically significant increase in HPD use during both intervention follow-up periods was observed compared to pre-intervention levels. All four groups improved their HPD use at two months post-intervention. The only intervention group that sustained statistically significant positive changes across the entire follow-up period was the group that had all three interventions (training, TB and NLI). Overall, these results indicate that the research improved HPD use among the participating workers, and potentially reduced their risk of developing NIHL during their career.
The research findings demonstrated that the hearing conservation training developed was successful at increasing use of HPDs in construction workers, a group which has historically showed poor acceptance of personal protective equipment. As a result, the one-hour and TB training materials have been shared with dozens of contractors and trade groups and posted it online for free download. "Train-the-trainer" sessions has been conducted with 21 construction safety professionals from around Washington and Oregon to allow for further dissemination of the materials. Many of these companies had ineffective or non-existing hearing conservation programs prior to training. The success of the NLI in this study contributed to the commercial launch of a modified version of the product (the 3M "Noise Badge"), which subsequently has received a health and safety award from Occupational Health and Safety. The commercial availability of the "Noise Badge" represents an important and tangible step towards preventing NIHL among US workers.
The study was innovative in several ways when compared to previous studies designed to reduce NIHL among construction workers. First, the use of a validated method of assessing HPD use (through a combination of dosimetryand task cards) allowed for a more thorough and rigorous evaluation of HPD use than traditional approaches reliant on questionnaire results. The finding that HPD use reported via questionnaire substantially overestimates actual HPD use highlights an importance weakness is previous studies. Second, the creative use of multiple intervention groups has allowed the benefits associated with different interventions to be evaluated. The finding that the only intervention group that sustained significant positive changes was the group that received all three interventions (training, subsequent TB training, and use of NLI) suggests that future interventions to increase use of protective equipment in construction would benefit from the use of a multi-prong intervention strategy. Third, the efforts to develop an innovative and flexible training program which could be administered by either experts or peer trainers were successful; no difference in trainee outcomes between the two types of trainers was found. Fourth, the innovative consideration of safety culture demonstrated that workers at sites with high safety climate scores had increased odds of HPD use. This finding has important implications regarding the effects of management support for safe work practices. Finally, the novel NLI developed with a corporate partner was shown to significantly contribute to worker’s using HPDs in a sustained fashion. The incorporation of the NLI into this research design was innovative, and the subsequent commercial availability of a modified version of the device represents an excellent example of "research-to-practice".
Noah Seixas, PhD, University of Washington
Richard Neitzel, PhD, University of Washington
Hendrika Meischke, PhD, University of Washington
William Daniell, MD, University of Washington
Lianne Sheppard, PhD , University of Washington
Jane Edelson, MS, University of Washington
The National Occupational Research Agenda Partnering Award
The National Occupational Research Agenda Partnering Award for Worker Health and Safety honors groups who have demonstrated exemplary teamwork, innovative thinking, and strong science in their collaborative partnerships on occupational health and safety research.
The 2011 Award recipient is Rollover Protective Structure (ROPS) Rebate Program
The ROPS Rebate Program Partnership was launched in November of 2006 to address the NORA Agriculture, Forestry and Fishing (AFF) program's single highest priority: "To reduce the number of fatalities due to overturns of tractors in agriculture by 50%, through the use of Roll-Over Protective Structures (ROPS) or similar technologies, by 2018". Tractor overturns are the most frequent cause of death in agriculture and estimates from Kentucky indicate that for every overturn fatality there are approximately five non-fatal injuries, 13% of which lead to a permanent disabilit. Based on estimates from the National Safety Council and estimates on the number of annual tractor overturn deaths, tractor overturns cost society well over $100 million annually.
Although tractor overturn fatalities have been virtually eliminated in other developed countries through a combination of legislation and financial assistance, these mandates do not exist in the US. Consequently, roughly half of U.S. tractors lack ROPS protection. Repeated education interventions and more recently proposed policy interventions have failed to successfully promote installation of ROPS. In 2004 the Northeast Center for Agricultural Health (NEC) was awarded supplemental funding from NIOSH to undertake the formative research needed to develop a social marketing intervention aimed at increasing the installation of ROPS in New York State. Initial data from telephone surveys indicated that over 76,000 tractors in New York were unprotected. Survey data gathered on farmer’s readiness to install ROPS indicated that while readily acknowledging the importance of ROPS, three-quarters of NY farmers were not considering retrofitting unprotected tractors. This data also indicated that small crop and livestock (SCL) farms accounted for 86% of farms with none or only one ROPS protected tractor. Due to the elevated risk of SCL farms, this group was selected as the intervention target.
As mentioned previously, social marketing was the strategy selected to develop the ROPS intervention program. Social marketing is mostly commonly employed when the target audience is knowledgeable about an issue, but is insufficiently motivated or capable of acting. In order to motivate individuals to make healthy choices, researchers seek to understand the issue from the community's perspective. With this understanding, researchers can then work to make the healthy behavior easier, more appealing and/or more cost effective.
To prepare for the development of the ROPS intervention, considerable formative qualitative research was conducted with various members of the SCL community. This included extensive in-depth interviews, the results of which were then reviewed by regional SCL farmer advisory groups. These regional SCL farmer advisory groups were organized early in the formative research phase and met on a biannual basis to review research data, to direct different aspects of intervention development and to network with the agricultural community to raise funds and social, as well as political support for the program.
The data gathered in interviews identified a complex of reasons why farmers were 1) not considering retrofitting and 2) perceived little personal risk from tractor overturn. The high price of ROPS, as well as, the logistical difficulty comparing, selecting, ordering and shipping ROPS were identified as the most significant logistical barriers. Concerns about injury to family members and employees and the desire to avoid permanent injury, emerged as potential motivators.
With considerable assistance from advertising consultants these findings were converted into marketing themes and potential advertising messages. These were tested with more than twenty small focus groups drawn from the SCL target audience and reviewed by the SCL farmer advisory group. Based upon comments from the farmers, the three top-rated messages were extensively revised. The National Agricultural Statistical Service (NASS) surveyed 1500 SCL farmers regarding their preferred information sources and a formal marketing plan was developed.
In addition to developing persuasive messages, a toll-free hotline was established to assist farmers with identifying the various ROPS options for their tractor. This hotline provided farmers with information on comparative prices, availability, shipping costs, issues to consider when self-installing and contact information for ordering ROPS. In order to address the considerable cost of purchasing and installing ROPS ($700-$1000), a series of meetings with NY legislators culminated in a $200,000 grant to provide farmers with partial rebates (70% of all costs up to a maximum of $765) for the cost of retrofitting. These efforts were greatly enhanced by farm bureau partnerships. As well as providing political support, the NY Farm Bureau provided promotional opportunities through mailings to memberships, free advertising and articles about the ROPS program in their monthly publication. The Northeast Equipment Dealers Association (NEDA) and Farm Family Insurance also provided considerable promotional assistance, using networks and member mailings to develop interest in, as well as support for the program.
The evaluation of the intervention program was extensive. The hotline provided a wealth of data on numbers of calls, numbers of retrofits, types of tractors retrofitted, manner of installation, problems encountered and farmer satisfaction with the program. A quasi-randomized, controlled trial was also designed to test the efficacy and impact of different incentive combinations (i.e. rebates only region, rebates + promotion region or 'the social marketing region', promotion only region and a control region). Promotional activities included newspaper interviews, radio talk shows and TV news briefs which were targeted by zip code to prevent media coverage from traveling into study regions not targeted for promotion. Telephone interviews by National Agricultural Statistics Service (NASS) gathered pre and post intervention data on stage of change regarding ROPS retrofitting and determinants of planned behavior from representative samples of SCL farmers in each of the test regions. Program partners from John Deere also worked to provide data on pre and post intervention ROPS sales in the different study regions.
Results from the pilot study were encouraging. John Deere data indicated a ten-fold increase in ROPS sales in the social marketing region. NASS surveys of SCL farmers in each of the regions documented significant increases in stage of change in the social marketing region and rebates only region (p <.016), as compared to other intervention regions. Farmers in the social marketing region displayed significantly greater advertisement recall (p<.0001). The most significant increase in intention to retrofit was demonstrated in the social marketing region (p<.003).
Based on the results from the pilot study, the incentives and interventions employed in the social marketing region were expanded throughout NY. At the end of the initial 12 months of the program expansion over 900 farmers had contacted the hotline, with roughly 300 committing to order a ROPS kit. After four years, 840 farmers have installed ROPS through the program and 63 potentially fatal incidents have been documented among roughly 500 of these participants. A cost benefit analysis of the study, indicated that based on injuries and fatalities prevented as a result of the intervention, a net savings could be demonstrated in the program’s third year. In addition, ninety-nine percent of program participants said they would recommend the program to other farmers and 98% said they felt safer driving their tractors now that ROPS had been installed.
In 2010 and 2011, the program expanded into Vermont, Pennsylvania and New Hampshire and several other states, such as Iowa, Maryland and Ohio, have indicated interest in bringing the program to their states. A ROPS rebate program website has also been developed, which provides information on the ROPS rebate program in participating states, tractor safety information, things to consider for participants seeking to self-install, tractor dealer information, tractor videos and opportunities to sign-up for the program online.
The development and implementation of the ROPS Rebate Program consisted of several stages and project partners were often involved to a greater or lesser extent depending on these stages. The lead agency throughout the process, however, has been the NEC. In the initial formative research phase, NEC researchers applied for feasibility grant funding, participated in the development of the study design and led efforts to collect and analyze the formative research data. However, several partners were involved in these initial efforts, as well. The NASS assisted by collecting survey data from several segments of the NY farm community. This data was used to identify the intervention target population. The SCL was also organized early on and provided oversight on research activities, feedback regarding research results and recommendations for subject recruiting. Once the formative research phase was completed, several new members joined the project team to develop and implement the intervention. These included NEDA, Farm Family Insurance, NY Farm Bureau and John Deere. NEDA provided excellent outreach opportunities by encouraging their network of tractor dealerships throughout the state to promote the program both visually (posters, counter displays, business cards, posters) and verbally with farm customers (instructing salesmen to talk with customers about the program). Farm Family Insurance also provided both promotional opportunities (mailings to customers), as well as financial contributions to help purchase paid advertising for the program. NY Farm Bureau provided considerable promotional support by placing free program ads in the monthly Farm Bureau Publication “Grassroots” and by mailing program information directly to their members. Farm Bureau was also instrumental in gathering political and grassroots support for the program and for state funding for rebates. John Deere worked with NEC researchers to evaluate the impact of the program by tracking ROPS sales in intervention and control counties. This proved to be one of the most effective ways of measuring the intervention’s impact on behavior change. NASS and the SCL were equally involved in the intervention implementation and evaluation phase. NASS conducted the baseline and follow-up surveys that were used to measure changes in readiness and intentions to retrofit, while the SCL continued to monitor the implementation of the intervention, provide feedback on intervention activities and evaluation results, and worked with members of the farm community to promote and build support for the program. Most importantly, the SCL selected the most appropriate advertisements and media channels. Once the NY implementation phase was completed, plans to export this program into neighboring states were made. In this phase, NEC worked with existing partners and Pennsylvania State University, the University of Vermont Extension and the New Hampshire Department of Agriculture. Each of these state-based partners conducted their own formative research, implemented their own state-based programs, worked to raise their own funding for ROPS rebates and evaluated the intervention with the assistance of NEC and local groups of farmers and agricultural service providers.
John May, MD, The Northeast Center for Agricultural and Occupational Health
Julie Sorensen, PhD, The Northeast Center for Agricultural and Occupational Health
John Lyons, The Small Crop and Livestock Farmer Advisory Group
Jim Judski, The Small Crop and Livestock Farmer Advisory Group
Carl Taber, The Small Crop and Livestock Farmer Advisory Group
James Minn, The Small Crop and Livestock Farmer Advisory Group
Ed Gates, The Small Crop and Livestock Farmer Advisory Group
Richard Carrier, The Small Crop and Livestock Farmer Advisory Group
John Pronko, The Small Crop and Livestock Farmer Advisory Group
Bruce Banks, The Small Crop and Livestock Farmer Advisory Group
Ted Teletnick, The Small Crop and Livestock Farmer Advisory Group
Steve Sinniger, The Small Crop and Livestock Farmer Advisory Group
Jeff Martin, The Small Crop and Livestock Farmer Advisory Group
Alan Pullis, The Small Crop and Livestock Farmer Advisory Group
David Collins, The Small Crop and Livestock Farmer Advisory Group
Ralph Gaiss, The Northeast Equipment Dealers Association
Rosemary Shader, Farm Family Insurance
Dennis Murphy, PhD, Pennsylvania State University
Aaron Yoder, PhD, Pennsylvania State University
George Cook, The University of Vermont Extension
Matt Myers, The University of Vermont Extension
Lorraine Merrill, The New Hampshire Department of Agriculture, Markets and Food
Julie Suarez, The New York Farm Bureau
Mike DeSpain, John Deere and Company
King Whetstone, National Agricultural Statistics Service
John Strand, Academy for Educational Development (AED) Center for Social Marketing and Behavior Change
Bithiah Lafontant, Academy for Educational Development (AED) Center for Social Marketing and Behavior Change
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