Total Worker Health in Action: March 2023
Volume 12, Number 1, March 2023
L. CASEY CHOSEWOOD, MD, MPH
To really impact the lives of workers, we must find ways to move beyond simply talking about worker well-being and focus on concrete actions to improve workers’ lives. This edition focuses on a crucial aspect of the Total Worker Health© approach: implementation. The stories below share inspiring actions NIOSH and our partners are taking to turn research into practice.
- Our Exclusive highlights a new implementation plan to promote research and improve healthy work design and well-being.
- This edition’s Promising Practice shares lessons learned from a pilot program in Italy where two plants implemented Total Worker Health (TWH) strategies.
- The latest news highlights examples of TWH in practice, including a closer look at how the Centers of Excellence for TWH transfer their research into practice through trainings, publications, and more.
A New Plan to Address and Advance Healthy Work Design and Well-being
A new implementation plan outlines actions to improve the work experience and prevent negative worker safety and health outcomes. An Implementation Plan for Healthy Work Design and Worker Well-Being: Addressing and Advancing the National Occupational Research Agenda was published by the National Occupational Research Agenda (NORA) Healthy Work Design and Well-Being (HWD) Cross-Sector Council in December 2022.
The NORA HWD Council works to protect and advance worker safety, health, and well-being by improving work design, management practices, and the physical and psychosocial work environment. Members from NIOSH, academia, industry, professional societies, and worker organizations and representatives make up the council.
In January 2020, the council published a research agenda. The agenda focuses on furthering research and interventions to advance worker safety, health, and well-being through healthy work design. The implementation plan aims to motivate researchers and other interested parties to address research objectives and identified gaps from the agenda. Key research objectives, defined in the research agenda, support and organize the plan. The plan describes possible initiatives, projects, products, or other actions to address research gaps and carry out each objective. The proposed actions seek to address a variety of current and emerging issues relevant to work design. These actions can protect and improve worker well-being by addressing work-related risks that add to poor mental health and by promoting safe, healthy, and supportive work.
The TWH approach highlights the fundamental role that high-quality work and healthy work design play in safer, healthier workers. For example, the plan’s fourth objective addresses “reducing work organization-related chronic health conditions among workers.” This objective specifies that advancing TWH principles, practices, and policies can be an effective way to improve the health and well-being of workers, addressing chronic disease risks both on and off the job. Learn more under objective 4.9, found on page 14 of the plan.
L. Casey Chosewood, MD, MPH, Executive Editor
Emily Kirby, Managing Editor
Sarah Mitchell, Associate Editor
Chia-Chia Chang, Contributing Editor
Cheryl Hamilton, Copy Editor
Steven Marra, NIOSH Web Developer
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The opportunities identified in the plan represent the council’s vision to progress science and practice through collaborative efforts. Partners can collaborate with council workgroups on any of the action items listed in the plan. Academic researchers, partner groups, coalitions, advocates, and all others who may be interested in collaborating or joining the council are invited to reach out to the HWD Council to explore ways to collaborate.
Implementing an Integrated Worker Health Model: A Summary of the TWH Pilot in Italy
Novelis Inc., an industrial aluminum company with manufacturing facilities on four continents, piloted the TWH approach as a framework to improve worker safety, health, and well-being. Through a multifunctional steering team and leadership commitment, Novelis successfully used the TWH approach to improve unhealthy aspects of work, increase prevention activities, and advance worker well-being.
Starting the Pilot Program
Company leaders believed the TWH approach could be a tool to help achieve their goal of eliminating workplace accidents. In addition, they thought it would complement existing initiatives and systems that would help enhance the company’s worker health strategy. To get started, Novelis conducted a global screening process focused on key TWH elements to determine specific areas of improvement. Novelis then launched a 6-month pilot at plants in Bresso and Pieve, Italy. The two plants were chosen based on past focus on occupational health issues and successful health campaigns conducted over the last 15 years. After conducting an assessment using previously acquired health data, Novelis learned that many elements for a TWH approach were already part of the plants’ existing worker health efforts. However, the assessments clearly identified opportunities for additional focus areas, structure, and intervention activities.
Many different elements made up the pilot program including policy, safety, occupational health, and health promotion:
- Policy: The most innovative aspect of the program was the creation of a multifunctional steering team that included the director of operations, plant physician, and leaders representing operations, environment, health and safety, and human resources. This team used input from various employees and other interested parties to set priorities for the program and to make sure the pilot was going in the right direction.
- Safety Management and Reduction of Occupational Risk Exposures:
- Ergonomic improvements for working operations and stations
- Respiratory protection through routine environmental monitoring and training on correct usage
- First-aid procedures and regular refresher training
- Noise reduction through personalized hearing protection
- Occupational Health: During safety briefings, the teams in Bresso and Pieve provided monthly updates on efforts and shared ideas. Occupational health professionals in the two plants discussed processes on any similar risk exposures. Industrial hygiene specialists also exchanged ideas about managing difficult medical cases about fitness to work and injury prevention.
- Health Promotion: Individual health activities developed in the Pieve employee gym helped to reduce the potential for injury by improving physical health, muscle tightness, strength, and balance. This activity was open to production and office workers. The two plants also began collaborating with a Milan hospital to identify heart health risks and Type 2 diabetes frequency in a production worker population. This effort will include one-on-one health education and nutrition counseling, and end with a program evaluation.
To realize the full potential of the TWH approach, Novelis leadership found that gaining support was critical. This included time and expertise from workers and leaders of all functional groups. The launch of the TWH program required an inclusive, diverse group of workers across all elements of the organization, from workers on the shop floor, worker representatives, shift leaders, and supervisors.
Increased communications and high visibility health messaging helped the plants stay focused on safety and health. Communications continued during safety briefings or with teams while they worked. Leadership created a unique logo to represent elements of the TWH pilot programs and identify safety actions. These actions included improving ergonomics at equipment centers, substituting chemicals, eliminating chemical or physical hazards, communicating on message boards, and healthier food options in the cafeteria and vending machines.
Finally, while the TWH approach helped improve safety, Novelis found that long-term success would require customizing programs based on worker preferences, experience levels, shifts, and job duties and tasks. Improving the onsite availability of healthy foods options is also needed.
What’s Next for Novelis
The two plants continue to analyze their approach and seek opportunities to improve. Although progress slowed during the pandemic, the sites continued efforts and will use some of the early lessons to move forward. Novelis shared the achievements from the pilot at Pieve and Bresso with the global Novelis community. Based on the success, Novelis incorporated the TWH approach as part of their 5-year Environmental, Health, and Safety Roadmap. Learn more about Novelis.
Project Contributors: Laura Basile – Director of Operations Novelis Italy; Dr. Valentina Belluigi, Bresso and Pieve Plant Physician; Silvio Zampirolo – EHS Leader Bresso; Marco Cavaliere – EHS Leader Pieve; Ugo Ciccotti – EHS Coordinator Pieve; Jan Van Den Ouweland – Novelis Europe EHS Manager; Jason Hudson Sr. EHS Manager Novelis North America
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.
A new blog describes how NIOSH research aims to address substance use disorders in the workplace. The blog shares highlights from a recent article that summarizes existing research and explores the meaning of workplace supported recovery. Workplace supported recovery programs prevent work-related risk factors that may lead to opioid use. They also help workers get the care they need and aid in recovery if it becomes necessary. Through these programs, employers use evidence-based policies and programs to reduce multiple risk factors. Learn more about workplace supported recovery.
Don’t Miss the Next TWH Webinar on Keeping Temporary Workers Safe
Register today for a free webinar on Tuesday, April 11 at 1:00 p.m. (ET). Keeping temporary workers safe can present unique challenges, as host employers and staffing companies are jointly responsible for ensuring a safe and healthy working environment. During this webinar, experts will share how host employers can address these challenges. Free continuing education is available.
Overcoming Workplace Ageism
Gigi (Gretchen) Petery, PhD, from the NIOSH TWH Program, joined the Center for the Promotion of Health in the New England Workplace for a TWH Trends webinar about supporting aging workers and overcoming workplace ageism. Watch the recording now!
Recorded Webinar on Work-life Boundaries: Continuing Education Opportunity
A recording of the November 2022 TWH webinar is available for free viewing and continuing education. The webinar focused on navigating work-life boundaries. It features Beth Livingston, PhD, from the University of Iowa, and Katrina Burch, PhD, from Western Kentucky University. Access the recording and learn more about how to get free continuing education on the TWH webinar series page.
Watch Highlights From the 3rd International Symposium to Advance TWH
Recordings from the 2022 Symposium are now available on YouTube. Watch the opening ceremonies, keynote presentations, closing remarks, and award ceremonies. Don’t forget to search #TWHSymposium on social media for ongoing updates from the event.
- The California Labor Laboratory will host their 2nd annual virtual conference May 2–3 at 8:30 a.m. (PT). The conference theme is “Data Gathering and Surveillance in Contemporary Employment: for Good or Bad?” The first day will focus on negative effects of monitoring and surveillance, and the second will focus on how to use these technologies to improve worker health and well-being. Stay tuned to their website for updates.
- The Carolina Center for Healthy Work Design and Worker Well-being (Carolina Center) hosted the Southeastern Summit on Healthy Work Design and Worker Well-Being in December 2022. Attendees learned about TWH, shared information about work-related activities underway in the region, and participated in working groups to help establish regional priorities. Researchers joined other centers during a panel presentation at the Health Enhancement Research Organization Winter Think Tank Conference to introduce TWH strategies and help facilitate future partnerships and collaborations. Earlier this spring, researchers presented on setting TWH priorities with key stakeholders at the Southeast Regional Research Symposium/SouthON meeting.
- The Center for Health, Work & Environment (CHWE) is offering two funding opportunities for pilot projects. The projects should address protections from work-related safety and health hazards and promote injury and illness prevention. Applications are due March 31 and are not restricted to geographical region. In addition to continuing their research on cancer at work, CHWE researchers are studying mental health. Researchers studying mental health emergency preparedness for the school workforce formed an interdisciplinary team to guide intervention development. Another study of mental health in farming populations focuses on gaining input from agricultural workers across communities.
- Center for the Promotion of Health in the New England Workplace (CPH-NEW) researchers are engaging educators and worker advocates to use new adaptions of the Healthy Workplace Participatory Program. The adaptions are designed to support TWH approaches for improving worker well-being. The center is also helping teachers in two schools apply the “IDEAS” design process to address stress from work overload. It is also providing train-the-trainer courses to build TWH leadership skills among unions serving healthcare workers. This spring, the outreach core will highlight TWH in talks to the Connecticut Small Business Association and the Connecticut Department of Labor’s Division of Occupational Safety and Health.
- The Center for Work, Health, & Well-being published an article describing the Thriving from Work Questionnaire. The article discusses dimensionality, reliability, and validity of the long and short form questionnaires. Stay up to date with the center on their website, LinkedIn, and Twitter.
- The Healthier Workforce Center of the Midwest (HWC) released a new podcast titled Work-Related Factors Impacting Suicide. This podcast highlights research using the National Violent Death Reporting System and looks specifically at work-related suicides. The findings provide insight into why work-related suicides happen and how the workplace can make a positive impact. HWC partners also released other new podcasts, including the St. Louis Area Business Health Coalition’s podcasts on improving worker well-being and the Nebraska Safety Council’s Connections podcast series.
- The Johns Hopkins Psychosocial, Organizational, and Environmental Total Worker Health® Center in Mental Health (POE Center) will host a virtual seminar during National Farmworkers Awareness Week focused on occupational health issues among agricultural workers. The center is excited to announce that the 2023 Carolyn C. Mattingly Workforce Health Award is now open. The award was established to help employers share best practices and to expose organizations to emerging data on practical solutions to protect and promote employee mental health and well-being. Learn more about the award and how to apply.
- The Oregon Healthy Workforce Center (OHWC) created toolkits that you can use in your workplace. The Active Workplace toolkit, available in Spanish, is an evidence-based program using the TWH approach to decrease sitting time in the workplace. The COMPASS toolkit for home care workers uses a peer-led social support group format designed to improve social well-being, reduce the risk of injuries, and promote health among home care workers. Stay up to date on staffing news and resources through OHWC’s blog and podcast, including new episodes about sedentary work and the Oregon TWH Alliance.
- The University of Illinois at Chicago (UIC) Center for Healthy Work aims to better understand leadership concerns and workforce health priorities at an integrated healthcare system through the project “Our Workforce Health and Well-being for All as a Sustainable Business Strategy (4All).” Researchers are analyzing data from 19 leadership interviews. The center is proud to partner with Arise Chicago on the Suburban Cook County Worker Protection Program. The program aims to promote and protect the rights, health, and safety of workers by creating strategic partnerships to better enforce Cook County Minimum Wage and Earned Sick Leave ordinances.
- The Utah Center for Promotion of Work Equity Research (U-POWER) hosts their annual spring conference on April 13 starting at 8:30 a.m. (MT). The conference theme is “Collective Action to Advance TWH.” The keynote presentation from labor advocate and law student Anthony Tenney will be livestreamed. At that time, U-POWER will share more information about funding opportunities through a mini grant and Research Pilot Project Program. Subscribe to the U-POWER newsletter to stay connected and learn about ongoing events.
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.
Decent Work for All: New Policy Document
The American Public Health Association (APHA) recently posted a policy document titled Support Decent Work for All as a Public Health Goal in the United States. The document was a collaboration from a group of safety and health professionals, including researchers from the Centers of Excellence for TWH. The authors aim to further the discussion on decent work and healthy work. The policy promotes decent work as a U.S. public health goal through a comprehensive approach that builds on existing APHA policy statements and addresses statement gaps. Stay tuned to future updates from the NIOSH TWH Program as we take a closer look at the policy document.
Guide on Creating Healthy Work Environments
The International Social Security Association published a Vision Zero guide on how to create a healthy work environment and promote well-being at work. “Vision Zero” is a transformational approach to prevention that integrates the three dimensions of safety, health, and well-being at all levels of work. Visit the Vision Zero website to learn more about the approach and to find translated versions of the well-being guide.
Occupational Safety and Health Training for Community Health Workers
In January, the Massachusetts Coalition for Occupational Safety and Health had a training on occupational safety and health for community health workers (CHW) employed by community health centers. The training, which will be continually offered, will help CHWs assist their working clients who have workplace issues like poor health and safety, wage theft, discrimination, and other abusive conditions.
TWH Approaches at SAIF, Oregon’s Not-For-Profit Workers’ Compensation Company
Behavioral health provider Trillium Family Services worked with the State Accident Insurance Fund (SAIF) to design a TWH approach using CPH-NEW’s Healthy Workplace Participatory Program (HWPP). SAIF is Oregon’s not-for-profit, state-chartered workers’ compensation company. The goal was to increase staff’s sense of safety and support in a field where assault-related injuries, burnout, and high turnover are common. SAIF employees completed TWH Facilitator training from CPH-NEW and facilitated implementation of the HWPP virtually during the pandemic. Hear from Trillium Family Services employees on their experiences with the program at SAIF Stories.
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.
The Center for Intelligent Environments (CENTIENTS) is in the Viterbi School of Engineering at the University of Southern California. CENTIENTS supports user-centered research and brings together leaders, scholars, innovators, and intellectuals from engineering to psychology to business to policy. Our goal is to engage in dialogue and debate, to forward work on intelligent built environments, and to form partnerships promoting human-centered design and integration of intelligent technologies into built environments.
To address old and new challenges, CENTIENTS builds on the fourth industrial revolution’s advances. This incorporates automation, machine learning and artificial intelligence, and smart technologies into conventional work practices and the built environment. Incorporating these technologies, research trajectories, and innovation opportunities into a broader set of changes, result in stronger partnership networks, greater agility and flexibility, and thoughtful futureproofing. CENTIENTS aims to lead the conversation that is centered around the worker, work, and workspace.
Our projects span a wide range of work environments. Examples include understanding health and well-being (stress, ergonomics) in office work and workspaces, occupational health, and safety on construction sites. Future work includes remote operation of construction equipment, hybrid work arrangements, virtual offices with virtual and augmented reality technologies, machine learning and artificial intelligence, and the impact of these technologies on worker well-being, health and safety.
The Society for Occupational Health Psychology (SOHP) is a nonprofit professional organization. We conduct and share psychological research about occupational health and worker well-being via scientific journals. Some of our work involves the development and evaluation of workplace interventions. Other work aims to translate and apply findings from psychological research to directly help workplaces and workers. SOHP will launch a blog series to increase communication about efforts to advance TWH research and practice. Check the SOHP website for updates.
The work that SOHP and its members do is very closely aligned with TWH. We consider and address factors at multiple levels including (1) organizations, such as leadership, structure, policies, and practices; (2) jobs, which consist of the job characteristics, work activities, and tasks being performed; and (3) workers, which include attitudes, perceptions, behavior, experiences, and individual differences. We identify risk factors and areas for intervention to advance both the science and practice of improving health and well-being at work.
The University of California, Davis (UC Davis) is a land grant institution with a mission of teaching, research, public service, and patient care. The mission, vision, and strategic goals of UC Davis align closely with those of TWH in that the university recognizes the importance of worker health and well-being as essential to the success of teaching students, performing cutting edge research, community service, and patient care at our medical center and patient care network. The university is continually working on advancing a culture of safety, health, and engagement through job design and organization of work, leadership, policy, built environment, psychosocial environment, and other supports that increase opportunities for greater employee safety, health, and well-being.
UC Davis is guided by the Principles of Community, in which administration recognizes that each member of the UC Davis community has an obligation to build and maintain a culture and climate based on mutual respect and caring. UC Davis, including UC Davis Health, is actively working on several issues relevant to advancing worker well-being using TWH approaches. Two units that have adopted the TWH approach as part of their objectives and goals are the Ergonomics Program and the Staff and Faculty Health and Well-being Program housed under Occupational Health Services.
UC Davis became a TWH Affiliate in 2022. UC Davis values networking and developing best practices. As a TWH Affiliate, we can be part of a network of progressive organizations who all share the same vision to build a healthy work environment and improve worker well-being.
As a new TWH Affiliate, we are delighted that we have been able to engage programs and research partners across the Davis and Sacramento campuses to join in on our pursuit of a healthy workforce and built environment. We have been able to identify the strengths, weaknesses, and opportunities that exist within our organization to cultivate a heathier and more productive work environment while minimizing the risk of losses.
Through networking and sharing knowledge and best practices, all parties involved benefit from one another’s expertise and results. For example, in 2022, through collaboration with University of California in San Francisco (UCSF), we were able to develop a meaningful course in office ergonomics. So far at both campuses (UCD and UCSF), this online course has helped nearly 800 staff and faculty to detect and address their office ergonomics issues at an early stage.
From CDC and NIOSH
- Employment Precarity and Increased Risk of Hazardous Occupational Exposures Among Residents of High Socioeconomic Hardship Neighborhoods
- Workplace Supported Recovery: New NIOSH Research Addresses an Evolving Crisis
- Workplace Supported Recovery From Substance Use Disorders: Defining the Construct, Developing a Model, and Proposing an Agenda for Future Research
From Our Partners
- Association Between Precarious Employment and BMI in the United States
- Changes in Precarious Employment and Health in the United States Amidst the COVID-19 Pandemic
- Health Equity and Worker Justice in Temporary Staffing: The Illinois Case
- Healthcare Organization Policies for Employee Safety and COVID-19 Pandemic Response: A Mixed-methods Study
- Latin American Agricultural Workers’ Job Demands and Resources and the Association With Health Behaviors at Work and Overall Health
- Firefighter Well-being Defined and Operationalized at the Organizational and Worker Level
- Protecting Temporary Staffing Workers in Illinois: A Policy Analysis
- Participatory Design of a Sleep Intervention With Correctional Supervisors Using a Root Causes Approach
- Oregon Healthy Workforce Center FY2022 Annual Report
- Occurrence of Occupational Injuries and Within Day Changes in Wet Bulb Temperature Among Sugarcane Harvesters
- Support Decent Work for All as a Public Health Goal in the United States (policy number 20223)
- Thriving From Work Questionnaire: Dimensionality, Reliability, and Validity of the Long and Short Form Questionnaires
- TWH and Organizational Behavior Management: Emerging Opportunities for Improving Worker Well-being
- Work-family Conflict and Depression Among Healthcare Workers: The Role of Sleep and Decision Latitude
- Work: A Social Determinant of Health Worth Capturing
3, 10, 17 – Register for the Train-the-Trainer course “Building TWH Leaders for Unions and Worker Organizations.” The course engages staff and members of unions and worker organizations to strengthen their facilitation skills, assess and build collaborative labor management relationships, and implement a TWH program.
6 – Deadline to submit proposals for Work, Stress, and Health 2023.
16 – Join a U-POWER Seminar Series at 4 p.m. (MT) on Zoom (Passcode: 272624). The seminar will feature guest speaker, Emma Vignola, who will discuss her research on New York City food workers’ experiences of precarious employment.
21 – Chia-Chia Chang, MPH, MBA, from the NIOSH TWH Program, will present about the NIOSH Worker Well-Being Questionnaire (WellBQ) at the American College of Preventive Medicine conference.
22 – L. Casey Chosewood, MD, MPH, Director of the NIOSH Office for TWH, will present at the Health, Environment, Safety, and Security Seminar in Dallas.
23 – Chia-Chia Chang, MPH, MBA, will speak about intervention strategies for physician burnout at a virtual American Thoracic Society town hall.
30 – The Society for TWH will host a peer learning series focused on healthcare and hospitals. This series will elevate evidence-based practices and highlight professionals who are actively applying the TWH approach within their organizations and workforce.
4 – L. Casey Chosewood, MD, MPH, will discuss the future of worker safety, health, and well-being during a presentation for the American Equity Underwriters, Inc.
6 – CHWE will host an Annual Research Day, bringing together students, trainees, and local professionals to celebrate student research in environmental and occupational health. This annual event features research presentations from Certificate in TWH trainees, one of six CHWE training programs.
7 – The UIC Center for Healthy Work will cosponsor the 14th Annual Minority Health Conference at UIC (University of Illinois at Chicago). The conference is an annual event where professionals and students from allied health fields come together to uncover and focus on eliminating the health challenges encountered by marginalized populations.
11 – Register now for the NIOSH TWH webinar, “How to Keep Temporary Workers Safe at Work” at 1 p.m. (ET). During this webinar, we will hear from experts on how host employers can keep temporary workers safe and address unique challenges. First, Lauren Menger-Ogle, PhD, from NIOSH and Michael Foley, from Washington State Department of Labor and Industries, will present best practices for host employers. Next, we will hear from Brittany Sakata on this topic from the perspective of the American Staffing Association. A question-and-answer discussion with the audience will follow.
12 – The St. Louis Area Business Health Coalition (BHC) will host a community forum from 7:30 a.m.–12:00 p.m. (CT). The theme of the forum is “Building Immunity: The Science of Healthy Living.” Registration is free with code BHCCF2023.
13 – U-POWER will host a Spring Community Conference with the theme “Collective Action to Advance TWH.” The keynote presentation from labor advocate and law student Anthony Tenney will be livestreamed.
19 – L. Casey Chosewood, MD, MPH, will present on health worker mental health at the 2023 JNESO Convention.
20 – Chia-Chia Chang, MPH, MBA, will discuss the latest TWH strategies at a meeting of the Northern Virginia chapter of the American Society of Safety Professionals.
20 – The Health Links webinar series will continue with Cannabis in the Workplace: What Employers and Employees Need to Know at 11 a.m. (MT). Participants are eligible to claim SHRM, CHES, and CSP credits.
20-21 – The HWC will cosponsor the Occupational Health Symposium in Iowa City in conjunction with the Heartland Center. This symposium will address the ever-changing nature of work and the implications of these changes for the health, safety, and well-being of workers.
20-21 – The Nebraska Safety Council Conference will be held in Lincoln, Nebraska.
Save the Date
June 16 – OHWC’s Spring Symposium is a virtual professional development workshop that will examine the intersection of shift work, sleep, and worker health and safety.
August 3-5 – The National Association of Community Health Workers (NACHW) will host the NACHW Unity Conference and Annual Meeting. The event will be in-person and online. Community health workers and allies across the country are invited to submit an abstract, sponsor, and attend.
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.