Total Worker Health in Action: December 2022
Volume 11, Number 4, December 2022
L. CASEY CHOSEWOOD, MD, MPH
The Total Worker Health® team is still celebrating the success of the 3rd International Symposium to Advance Total Worker Health (TWH), held in October on the National Institutes of Health (NIH) campus. We are elated that so many of you, or representatives from your organizations, could join us. This was our largest symposium ever, providing global perspectives and novel insights with over 500 registered participants from 41 states and 18 countries. I’d like to personally thank all who attended and recognize the following:
- The Center for Health, Work & Environment (CHWE) team for coordinating and planning of an exceptional event and for serving our attendees so thoughtfully and professionally
- The NIH for hosting us yet again on their campus and for the variety and quality of health and well-being activities and nutritious food offered throughout the event
- Our NIOSH team, the Centers of Excellence for TWH, and the NIOSH TWH Affiliates, for their contributions and commitment to expanding TWH research and practice
- My colleague Dr. Adele Childress, the event’s co-chair and long-time member of the NIOSH TWH Core Team, whose dedication and leadership were instrumental in the symposium’s success
During the event, I had the pleasure of recognizing leaders in the field of TWH. I am grateful to these individuals for their outstanding commitments to advancing the TWH approach. These leaders are advocates for worker safety, health, and well-being who help produce new scientific knowledge and translate that knowledge into practice. I would like to extend congratulations and deepest appreciation to the following award winners:
TWH Founder’s Award
- Glorian Sorensen, PhD, MPH
- Steve Sauter, PhD
- Adele Childress, PhD, MSPH
- Laura Punnett, ScD
- Casey Chosewood, MD, MPH
- TWH Star Partner Award
- Sara Tamers, PhD, MPH
- Liz Hill, MPH, CIH, CSP
- Lili Tenney, DrPH, MPH
- Cortney Cuff, MBA
In a surprise move, the Symposium’s Award Committee recognized me with a TWH Founder’s Award, as noted above. I was shocked and truly honored. Learn more about these awards on the NIOSH Science Blog.
Don’t miss the TWH exclusive below to read highlights and takeaways from the symposium and check out the hashtag #TWHSymposium on social media for more! For the latest TWH news, research, and events, follow us on Twitter at @NIOSH_TWH, join our NIOSH TWH LinkedIn Group, or send us an email at TWH@cdc.gov.
L. Casey Chosewood, MD, MPH, Executive Editor
Emily Kirby, Managing Editor
Sarah Mitchell, Associate Editor
Cheryl Hamilton, Copy Editor
Steven Marra, NIOSH Web Developer
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Highlights From the 3rd International Symposium to Advance TWH
The 3rd International Symposium to Advance TWH featured the highest number of presenters and participants ever convened for the topic of TWH, including 8 pre-symposium workshops, 130 sessions, 23 posters, and 20 exhibitors. Presenters shared the latest science on TWH and integrated approaches, providing participants with unique instructional content and up to 19 hours of continuing education credits. Presentations covered nearly every traditional occupational safety and health topic as well as dozens of late-breaking talks on emerging risks, the impact of the pandemic, and the future of occupational safety and health. Participants learned about new research, practices, and partnerships since the last symposium, including lessons learned from the pandemic. The symposium agenda was full of compelling research! You can access session abstracts for more background on the presentations.
Shaping Work Now and in the Future
The symposium theme resonated in topics presented and reflected changes to the symposium itself, including a new hybrid format. This was the first time the symposium offered the hybrid format, with nearly 200 participants joining virtually. This new format engaged professionals from across the globe and allowed people to attend who may have been unable to otherwise. Another new offering this year, which expanded the reach of the symposium, was scholarships for attendees. Scholarships were awarded to 60 applicants, who received up to 100% off their registration costs.
Keynotes Highlight Critical TWH Directions, Old and New
During keynote addresses from Dr. Karina Nielsen and leaders from the Centers of Excellence for TWH, attendees learned about approaches to improve working conditions. Attendees also confronted equity issues with Earl Dotter and Saru Jayaraman. Earl Dotter presented on the Black worker experience, telling stories with his photographs, while Saru Jayaraman presented on the history of issues impacting food service workers and current efforts to address those issues. Read more about the presentations on the NIOSH Science Blog. A fireside chat with the U.S. Surgeon General put a spotlight on mental health, burnout, and worker well-being. Find a summary of the chat on an additional NIOSH Science Blog and stay tuned for the recording! You can also learn more about these efforts in the Promising Practice below.
Keep the Momentum Going
TWH concepts continue to evolve and reflect a growing field. The future promises new and existing challenges that require continued efforts across disciplines to implement policies, reduce disparities, and anticipate the impacts of new technologies. On the final day of the symposium, the newly launched Society for TWH™ hosted an inaugural meeting. The Society for TWH is a nonprofit member organization made up of individuals and partners dedicated to the advancement of worker safety, health, well-being, and productivity through TWH approaches. This effort is led by the Center for Health, Work & Environment at the Colorado School of Public Health, with each of the Centers of Excellence for TWH shepherding this new collaborative.
Continue looking for new ways to engage by searching the hashtag #TWHSymposium on social media and posting your takeaways from the event. Symposium attendees can access recordings and resources in the attendee hub until January 31, 2023. Did you miss the symposium or just can’t get enough? You can still register for the virtual track to access the online video library from the symposium. Learn more on the symposium website.
U.S. Surgeon General Shares Promising Practices for Worker Well-being
The Office of the U.S. Surgeon General (OSG) is a long-time champion for worker well-being and an invaluable partner in these efforts. The OSG highlights promising practices that workers, businesses, community organizations, and anyone interested can use to protect and promote worker well-being. The 20th U.S. Surgeon General, Jerome M. Adams, MD, MPH, delivered a keynote about worker health during the opening session of the 2nd International Symposium to Advance TWH in 2018. Later that year, Dr. Adams made a strong case for employers to ensure that workplace polices, programs, and practices advance the safety and health of workers in an article titled The Value of Worker Well-Being. The paper identifies promising practices that use upstream systems interventions to contribute to worker well-being. In 2021, Dr. Adams released another report called Community Health and Economic Prosperity: Engaging Businesses as Stewards and Stakeholders. This report identifies health challenges Americans face and describes how investments to nurture community health and well-being can help create conditions for businesses and communities to thrive.
Current U.S. Surgeon General, Vice Admiral Vivek Murthy, MD, MBA, is continuing efforts to promote worker well-being. Earlier this year, Dr. Murthy joined NIOSH Director Dr. John Howard and other national experts during a call-to-action webinar to launch the NIOSH Health Worker Mental Health Initiative. Dr. Murthy is a strong advocate for mental health, publishing advisories on youth and health workers, as well as serving as co-chair of the National Academy of Medicine Active Collaborative on Clinician Resilience and Well-being. In case you missed it above, he also participated in a fireside chat about worker well-being and mental health during this year’s symposium.
Framework for Workplace Mental Health and Well-being
In October, Dr. Murthy released a document titled Framework for Workplace Mental Health and Well-being to raise awareness of these issues. The framework will powerfully stimulate conversations and changes in organizations and workplaces. It identifies five essentials that support workplaces as engines of well-being, with each essential based on two human needs. Worker voice and equity is central to the framework, highlighting the importance of worker engagement – a fundamental element of the TWH approach. Members of the NIOSH TWH Core Team were honored to participate in its development. The five essentials are listed below, along with key components that can serve as promising practices for organizations collaborating with workers to implement the framework:
Protection From Harm
- Prioritize workplace physical and psychological safety
- Enable adequate rest
- Normalize and support mental health
- Operationalize diversity, equity, inclusion, and accessibility (DEIA) norms, policies, and programs
- Connection and Community
- Create cultures of inclusion and belonging
- Cultivate trusted relationships
- Foster collaboration and teamwork
- Work-Life Harmony
- Provide more autonomy over how work is done
- Make schedules as flexible and predictable as possible
- Increase access to paid leave
- Respect boundaries between work and nonwork time
- Mattering at Work
- Provide a living wage
- Engage workers in workplace decisions
- Build a culture of gratitude and recognition
- Connect individual work with organizational mission
- Opportunity for Growth
- Offer quality training, education, and mentoring
- Foster clear, equitable pathways for career advancement
- Ensure relevant, reciprocal feedback
Applying the Framework
Workplaces and leaders wanting to implement the framework can review practice examples to get started. The framework can inspire and inform research, investments, and broader policies. Organizations, policymakers, researchers, and others can use the framework to identify opportunities to improve and implement innovations. During these efforts, they can also use the NIOSH Worker Well-Being Questionnaire (WellBQ) to track changes in workers’ perceptions of the physical environment and safety climate, work evaluation and experience, work policies and culture, health status, and home, community, and society. The framework’s holistic approach and focus on healthy work design aligns with the NIOSH worker well-being framework. The NIOSH TWH Program continues to work with the OSG to stimulate dialogue, sustain healthy cultures, and help workers and organizations thrive and reach their full potential.
Editor’s note: If you or someone you know needs assistance (in English or Spanish) with mental health concerns or substance use disorders, prevention, and recovery, please contact the Lifeline at 988 or visit the Lifeline webpage.
Recovery-ready Workplace Resource Hub
A new resource hub is available with information about recovery-ready workplaces for workers and employers. The hub, inspired by a cross-government initiative led by the White House’s Office of National Drug Control Policy, includes an overview of policies and practices that makes a workplace recovery-ready and shares the benefits of these policies. NIOSH and colleagues at the U.S. Department of Labor contributed extensively to this project. Visit the hub for more information and links to other resources.
Continuing Education Available: NIOSH TWH Webinar Recordings
In October, the webinar “Promoting a Sustainable Work-nonwork Interface” discussed work schedules in the aftermath of the COVID-19 pandemic. There was also discussion about COVID-19 and women, including strategies to address the impact on women’s workforce participation. Access the recording and learn more about how to obtain free continuing education on the TWH webinar page. Also, stay tuned for a recording from the November webinar featuring strategies for navigating work-life boundaries.
Santa’s Workshop Keeps Spirits Bright With TWH Strategies
Get in the spirit with this holiday inspired NIOSH Science Blog. You can discover how Santa uses TWH approaches to protect elves and promote their well-being!
Whole Person Health Stakeholder Meeting
In October, Heidi Hudson, MPH, Commander, U.S. Public Health Service, participated in a stakeholder meeting sponsored by the National Center for Complementary and Integrative Health (NCCIH) on future research on “whole person health.” NCCIH identifies whole person health as looking at the whole person—not just separate organs or body systems—and considering multiple factors that promote either health or disease. Meeting participants considered what kind of research is needed and how to implement this concept in real-world settings. CDR Hudson provided comments to NCCIH on behalf of the NIOSH TWH Program. Learn more about NCCIH’s initiative on Whole Person Health.
- Researchers from the California Labor Laboratoryenjoyed participating in the symposium, delivering various presentations. They recently released a request for proposals for pilot grants, due March 1, 2023. Stay tuned to their website for the latest news on upcoming webinars.
- The Carolina Center for Healthy Work Design and Worker Well-being (Carolina Center) served as the organizing theme for a stop on the Tar Heel Bus Tour in October. The bus tour introduces Carolina faculty and senior administrators to the most pressing issues facing the state and to community-engaged research partnerships. The 40 bus tour participants were introduced to the Carolina Center and heard from workers about their experience with the two worksite projects. They also stopped at the RedEye Worldwide warehouse, a participant in the Carolina PROSPER study and a pilot site for the affiliated project testing healthy subsidized meals available in blue collar worksites. In the fall, the Carolina Center conducted a four-hour TWH professional development course for industrial hygienists at the regional American Industrial Hygiene Association- Carolinas. They also participated in the symposium, delivering five presentations, including a pre-symposium workshop by Center Director Dr. Laura Linnan.
- The Center for Health, Work & Environment (CHWE) is celebrating the launch of the Society for TWH™, which now boasts more than 120 members. The group’s inaugural event was held at the symposium. You can learn more about how to join the society and sign up for email updates. CHWE is excited to offer the TWHProfessional Program, an online training program that will help participants understand the benefits of the TWH approach and how to masterfully apply it in any organization. CHWE is also continuing to work on research projects, including the Well-being and Cancer at Work (WeCanWork) research study. The study has formed focus groups with care team members. The research team will recruit cancer survivors and occupational medicine providers to participate in December’s focus groups. Researchers recently received funding from the Institute for Cannabis Research to study the potential exposure to heavy metals from smoking or vaping cannabis.
- Center for the Promotion of Health in the New England Workplace (CPH-NEW) personnel were excited to participate in the symposium, delivering 17 presentations and celebrating founding Co-Director Dr. Laura Punnett. Dr. Punnett was honored with a TWH Founder’s Award for her leadership in advancing TWH and ensuring the voices of workers remain front and center. CPH-NEW intervention research studies are actively advancing, recruiting teachers for the Total Teacher Health study to participate in health and safety “design teams” in two school districts. The TWH Employer Crisis Preparedness study kicked off a one-year coached community of practice pilot training program for human resources and other management professionals. This month, CPH-NEW thanks out-going Co-Director Bill Shaw, PhD, for his leadership as he prepares for retirement and welcomes Jennifer Cavallari, ScD, in her new role as Co-Director.
- The Center for Work, Health, & Well-being was well represented at the symposium and thoroughly enjoyed participating as presenters and attendees. Researchers were represented in a keynote address on “Approaches and Challenges to Improving Conditions of Work Across Industries” and a panel discussion on “Accelerating Research to Practice: Connect With NIOSH TWH Centers,” along with other center outreach directors. Other presentations included “Work Organization as a Core Dimension of TWH: Toward an Expert Consensus,” “Development of the Thriving From Work Questionnaire: A Measure of Work-Related Well-being,” “Mental Health of Construction Workers,” and “Protecting Workers in the Post-pandemic World.” During the symposium closing session, Center Director Glorian Sorensen received a TWH Founder’s Award for her contributions to the field, recognizing her many years of expanding the evidence supporting workplace policies and practices designed to promote and protect workers’ safety, health, and well-being.
- The Healthier Workforce Center of the Midwest (HWC) published a new Workplace Mental Health Policy Brief. The brief outlines the benefits of addressing mental health in the workplace, describes strong mental health and return-to-work policies, and highlights best practices to promote mental health and safety. HWC also released a recording of the Collaborative Learning Community webinar, “More Than Just a Paycheck: Creating a Workplace That Attracts and Retains Employees.” The webinar addressed how work culture, policies, and practices influence health and well-being and impact recruitment and retention. In a new podcast, Protecting Worker Well-Being in Immigrant Populations, they examine Latino immigrant and migrant populations working in meatpacking and cattle feed yards.
- The Johns Hopkins Psychosocial, Organizational, and Environmental Total Worker Health® Center in Mental Health (POE Center) hosted its inaugural Summit on Mental Health in the Workplace in October in a hybrid format with over 100 attendees. The Johns Hopkins Bloomberg School of Public Health and The Luv u Projectannounced the inaugural winners of the Carolyn C. Mattingly Award for Mental Health in the Workplace (Mattingly Workplace Award), Akin Gump Strauss Hauer & Feld LLP, Metro Nashville Public Schools, and the University of Virginia. The award was presented for their comprehensive efforts to advance workforce mental health and psychological well-being. In addition to the 2022 Award winners, Associated Bank, Franklin County Cooperative, and General Electric received honorable mention recognition.
- The Oregon Healthy Workforce Center (OHWC) is offering a new certificate program, “TWH: Advancing Worker Well-being in the Workplace.” Course content will include an examination of TWH elements and concepts, an introduction to occupational health psychology and its relevance to safety and TWH, and a discussion of resources and strategies for integrating safety and occupational health into organizations. OHWC is celebrating 4 years of their podcast, What’s Work Got To Do With it?, where listeners can enjoy over 30 episodes, including a new addition on Fishing Forward for fishermen. OHWC is also celebrating the success of the symposium, where researchers delivered seven presentations. OHWC sends thanks and appreciation to Dede Montgomery, who led outreach efforts at the Oregon Institute of Occupational Health Sciences for over 18 years.
- The University of Illinois at Chicago (UIC) Center for Healthy Workis working with an integrated healthcare system to improve workforce and population health and well-being by addressing benefits design, wage structures, and culturally appropriate and accessible well-being programs. Read about this new project called Workforce Health and Well-being for All as a Sustainable Business Strategy. UIC is also continuing their work on the Greater Lawndale Lotería, an evidence-informed, historically grounded, and worker justice-themed educational game to promote healthy work in Greater Lawndale by informing critical dialogue and shifting knowledge, attitudes, and beliefs. The game was played with community members and local youth and is available to download and print to play in your community!
- The Utah Center for Promotion of Work Equity Research (U-POWER) is collaborating with several community stakeholders, including county health departments and community health workers, to develop toolkits and training dedicated to safe, healthy, and equitable work. U-POWER is continuing development of our community-based certificate in TWH and developed a faculty mentorship program with an interdisciplinary cohort of graduate students to serve as subject matter experts. Both the mini grant program (dedicated to community-initiated research) and the Research Pilot Project Program are open for applications.
These are just a few of the updates from the NIOSH Centers of Excellence for TWH. To learn more about each of the Centers, visit their websites.
Applications Open for Workplace Mental Health Award
Mental Health America’s Bell Seal for Workplace Mental Health application is now open. The Bell Seal recognizes organizations committed to creating worker friendly and psychologically safe workplaces. To prepare aspiring employers for Bell Seal certification, Mental Health America created the Workplace Mental Health Toolkit, which includes resources to develop the foundation for a mentally healthy workplace. View past recipients in the Bell Seal 2022 Brief.
Healthy Work Pledge Spurs Critical Dialogue
The Healthy Work Campaign, a public health initiative of the Center for Social Epidemiology (a nonprofit and TWH Affiliate), is excited to introduce the Healthy Work Pledge. Want to know what we mean by “Healthy Work”? Check out the Pledge! The Pledge is designed to start a dialogue between employers, labor unions, government, health and safety professionals, and working people about how to reimagine U.S. workplaces to reduce sources of work stress and improve the health and well-being of workers. The coalition around the Healthy Work Pledge is growing. Sign up as an organization or individual to help build the movement for healthy work.
State of Mental Health in America Report
Mental Health America released its 9th annual report, ranking the 50 states and the District of Columbia on 15 indicators of the prevalence of mental health conditions and access to care for youth and adults. This report provides a snapshot of mental health status for policy and program planning, analysis, and evaluation. Read key findings and download the report.
TWH Welcomes a New Affiliates
The Massachusetts Coalition for Occupational Safety and Health (MassCOSH) strives to ensure that all workers earn their living and return home alive and well. MassCOSH unites workers, unions, and community groups with environmental and health activists, to end dangerous work conditions, to organize for safe, secure jobs, and to advocate for healthy communities. The National Association of Community Health Workers (NACHW) was founded in April 2019 after several years of planning and organizing by CHW leaders and allies across the country. Their aim is to establish a membership driven organization with a mission to unify Community Health Workers to support communities in achieving health, equity, and social justice. Learn more on the NIOSH TWH Affiliates webpage.
This feature was created to introduce our readers to current NIOSH TWH Affiliates. See how the NIOSH TWH Affiliates responded when we asked about their work.
Western Kentucky University is an institution of higher education.
TWH is incorporated into our undergraduate and graduate curricula in the Environmental and Occupational Health and Safety programs as well as the undergraduate and graduate courses for our Workplace Health Promotion certificates. Through the WKU Center for Environmental and Workplace Health, we incorporate TWH in the majority of our research projects. Some examples include assessing: faculty and staff well-being using the NIOSH WellBQ, workplace health promotion programs in Kentucky with a comparison to national trends, and training needs of occupational safety and health professionals.
Wilkes Recovery Revolution, Inc. is an accredited recovery community organization located in the foothills of the Appalachian Mountains in Western North Carolina. Through this accreditation, we are committed to providing free, non-clinical recovery support in addition to advocacy and community-building efforts. One of our eight unique programs is focused on educational attainment and workforce development efforts within the recovery population including a Recovery Friendly Workplace Initiative. This work allows us to partner with employers to combat stigma, increase support for job seekers and employees, and navigate recovery support in the workplace.
Since becoming an affiliate in May of this year, we increased our access to information and training on safety and wellness in the workplace, contributing to our prevention efforts and expanding on the resources we can provide to our employer partners. Citing NIOSH in our training and communications with employers brings validity and credibility to our efforts, and we feel peace of mind in knowing that some of our more complicated questions can be reviewed and researched in partnership with one of NIOSH’s regional research centers.
Spotlight on the Symposium
- Celebrating the 3rd International Symposium to Advance TWH
- TWH Symposium: A Closer Look at Keynotes
- Worker Well-being Takes Center Stage: Fireside Chat With the U.S. Surgeon General
- Celebrating the Success of the 3rd International Symposium to Advance TWH
- The Future of TWH Training
- Why We Need to Listen
- Power at Work: Reflections From the 3rd International Symposium to Advance TWH
- Connecting at the TWH Symposium
From CDC and NIOSH
- NIOSH Miner Health Program Addresses Substance Use and Work
- What Is Employment Quality? How Can We Study It for Occupational Health Equity?
From Our Partners
- Employment Precarity and Increased Risk of Hazardous Occupational Exposures Among Residents of High Socioeconomic Hardship Neighborhoods
- Healthcare Organization Policies for Employee Safety and COVID-19 Pandemic Response: A Mixed-methods Study
- How the Senior Community Service Employment Program Influences Participant Well-being: A Participatory Research Approach With Program Recommendations
- Primary Prevention of Weight Gain Among New Bus Operators: Results of the Success & Health Impacts for Transit Operators During Onboarding (SHIFT Onboard) Pilot Study
- Residential Addiction Treatment Providers: Identifying the Role of Social Context in Worker Health and Turnover
- Response to NIOSH Request for Information on Interventions to Prevent Work-related Stress and Support Health Worker Mental Health
- The Utility of a Safety Climate Scale Among Workers With a Work-related Permanent Impairment Who Have Returned to Work
- Weight Loss Program Preferences of Men Working in Blue-collar Occupations: A Qualitative Inquiry
5 – The Center for Work, Health, & Well-being will co-sponsor a seminar with the Harvard Education and Research Center at 1 p.m. (ET). Dr. Daniel Schneider, Malcolm Wiener Professor of Social Policy and Professor of Sociology in the Harvard Kennedy School at Harvard University, will present “Routine Uncertainty in the Service Sector.” He will discuss work scheduling practices in the service sector, the effects of exposure to precarious scheduling on worker health and well-being, the effectiveness of labor standards in reducing work schedule instability, and research on automation and technology in the service sector.
7 – Register for a free webinar, “The Role of Economic Security in the Future of Work,” at 12:30 p.m. (ET). This event is part of the NIOSH Future of Work Initiative Webinar Series. The webinar will address topics like adequate wages, equitable and commensurate compensation and benefits, and minimum guaranteed hours impacting the safety, health, and well-being of tomorrow’s workforce.
8 – U-POWER will host a December Seminar Series titled “Unpacking Power, Positionality, and Practice,” being held on Zoom at 4 p.m. (MT).
9 – OHWC will host a Fall 2022 Symposium, an online day-long event beginning at 9 a.m. (PT), focused on “supporting diverse workforce in the face of ongoing societal trauma.” Heidi Hudson from the NIOSH TWH Program will present on “Empowering TWH in a Traumatized Workforce” at the event. Register today.
14 – The Carolina Center will hold an inaugural Southeastern Summit for Healthy Work Design and Worker Well-Being. This event will gather a select group of key employers, labor leaders, government officials, policymakers, researchers, and practitioners. Together, they will engage in conversations about how to prioritize research, outreach and education and policy and practice-related activities to improve worker safety, health, and well-being across the Southeastern U.S. Director of the NIOSH TWH Program, Dr. L. Casey Chosewood, will provide remarks at the event.
U-POWER will host a Town Hall in January 2023 for community members interested in the mini grant program. Stay tuned to their website for a date and location.
3, 10, 17 – CPH-NEW expanded its flagship Healthy Workplace Participatory Program training with a streamlined version for unions and worker organizations. The “Building TWH Leaders: Train the Trainer,” part of the SHIFT project, engages staff and members of unions and worker organizations. The program helps to strengthen their facilitation skills, assess and build collaborative labor management relationships, and implement a TWH program in their labor management committees to address the root causes of worker health, safety, and well-being. Registration for February classes is now open!
15 – Health Links™, CHWE’s TWH employer advising program, hosts an annual TWH webinar series. The 2023 series will kick off at 11 a.m. (MT) with “Money Matters: Financial Well-being and TWH.”
Save the Date
April 13 – U-POWER will host a Spring Community Conference. The keynote address will be livestreamed.
Find more events on the NIOSH Conferences, Meetings, Webinars, and Events webpage.
Total Worker Health® is a registered trademark of the U.S. Department of Health and Human Services (HHS). Mention of any company or product does not constitute endorsement by the National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention. In addition, citations to websites external to NIOSH do not constitute NIOSH endorsement of the sponsoring organizations or their programs or products. Furthermore, NIOSH is not responsible for the content of these websites. All web addresses referenced in this document were accessible as of the publication date.