Summary of Abstracts
Future of Occupational Health: Practice
Garrett Brown, MPH, CIH
Coordinator, Maquiladora Health & Safety Support Network, Berkeley, CA
Problem statement: Manufacturing of many consumer goods in the global economy has shifted from relatively high-wage, well-regulated and partially unionized workplaces in the developed world to very low-wage, unregulated and essentially non-union workplaces in developing countries in Asia, Africa and Latin America. Working conditions in these supplier factories, often producing for internationally-known “brands,” are overwhelmingly unsafe, unhealthy and result in higher levels of injuries, occupational diseases and deaths. Producer countries have governments (often corrupt) without the resources or political will to protect their vulnerable worker populations, and frequently view any foreign investment as essential for economic development, no matter how deadly in the short-term.
Brief overview of suggested approach, solution, or research question: Several approaches are key to effectively protecting workers in global supply chains: (1) recognizing the characteristics of the current global economy (the “race to the bottom” and the brands’ “iron triangle” of lowest possible price, highest possible quality and fastest possible delivery); (2) recognizing that corporate social responsibility codes and monitoring programs have failed almost completely to improve actual working conditions; and (3) activities that center on building the capacity of worker and community organizations in producer countries to understand fundamental concepts of effective OHS programs at the factory level, and to understand workers’ rights under national and international law, so that workers and their organizations are able to speak and act in their own name to reduce and eliminate workplace hazards, injuries, illnesses and fatalities. The experience of the 20-year-old Maquiladora Health & Safety Support Network illustrates the success and challenges of this three-prong approach.
Jenna A. Gibbs, MPH PhD, Research Industrial Hygienist
Megan Casey RN, BSN, MPH, Epidemic Intelligence Service Officer
Neetu Abad, Psychologist/Behavioral Scientist
NIOSH Division of Respiratory Disease Studies, Health Hazard Evaluation Program of the Field Studies Branch, CDC, Morgantown, WV; and Office of Infectious Diseases (OID), CDC, Atlanta, GA
Problem statement: In developed countries like the U.S., occupational health training is often performed in a class room, on the internet, or at the worksite. The recent Ebola outbreak in Western Africa in 2014-2015 greatly highlighted the need for rapid occupational health training in developing nations. More timely training for health workers earlier in the Ebola response could have decreased infections among health care and first responder workers. This could have resulted in an overall decreased number of Ebola infections in the region. The resources available for occupational health training in developing countries are often limited. Some of the challenges for occupational health training we experienced in West Africa included limited access to technical support (e.g., internet, computers) and an inconsistent supply of personal protective equipment. Other training challenges were sociobehavioral, including barriers in language and communications, local adherence to traditional beliefs that do not coincide with western guidelines, limited understanding of basic hygiene/sanitation practices, and little preceding knowledge regarding cultural-specific learning styles. These challenges were often compounded by the perception that trainers are outsiders entering the community with different values and culture.
Brief overview of suggested approach, solution, or research question: We suggest that occupational health professionals work closely with groups in developing countries to improve occupational health training programs appropriate for these settings. Some potential solutions involve: a) building a local safety culture and infrastructure with anthropologists and sociobehavioral scientists to link with local beliefs; b) using more tactile learning and situation-specific drills rather than classroom learning; c) working with local interpreters to interpret and explain technical documentation; and d) providing ongoing mentorship of workers in the field to create a supportive environment that encourages continued learning and critical thinking. We plan to use our recent training experience during the Ebola outbreak in West Africa to highlight some specific examples.
Shilpa Gowda, MD
University of Washington Occupational and Environmental Medicine Resident Physician and MPH candidate
Problem statement: The Affordable Care Act (ACA) is expected to affect the system of Workers' Compensation Claims in many different ways, some that lessen the burdens on the system and some that increase it. It is necessary to train physicians specializing in occupational medicine to deal with the potential additional challenges to the system that the ACA may pose.
Brief overview of suggested approach, solution, or research question: The ACA may produce a number of challenges to the Workers' Compensation system. Some of these challenges relate to the increased number of patients, not met with a corresponding supply of treating physicians; and others may relate to increased part-time work incentivized by the employer mandate, which in turn increases the risk of occupational injuries. It is very important to prepare occupational medicine physicians to handle the expected challenges; such ways of preparing these physicians include through continuing medical education programs as well as through expansion of occupational medicine residency and fellowship programs.
Adegboyega Timothy Adewale
University of Alabama at Birmingham Occupational Health and Safety MPH student
Problem Statement: Workers above 65 years are entering into the full-time work schedules, compared to what obtains before the turn of the new millennium. The aging workforce constitute a healthcare challenge due to onset of chronic diseases and increased medical care costs, coupled with the fact that a vast majority of these workers are gaining weight/obese. As people continue to live longer, and as the baby-boomers join the ranks of those 65 years and above, the graying of the workforce is bound to see an upward trend. A consequence of this is the rise in OSHA Recordable and/or reportable injuries secondary to human factors incidents, as well as ergonomic issues.
Brief Overview of Suggested Approach, Solution or Research Question: I suggest that pre-employment medical assessment be mandatory for aging workers as a way to determine the task for which they are best suited (to minimize/prevent injuries). Part-time employment/opportunities to work from home could be explored, as well as volunteer involvement post-retirement, especially for jobs that would benefit from the experience and expertise of elderly workers. More emphasis needs to be placed on the concept of total worker health, which goes beyond ordinary work-safety practices to encouraging healthy lifestyle choices (encompassing physical, social, mental and reproductive health) for both young and old workers. Finally, public advocacy about the benefits of wise financial planning for retirement would help aging workers retire comfortably whenever they wish
Mailman School of Public Health, Columbia University, MPH Candidate
Problem statement: As the consequences of climate change become more drastic and irrefutable, how should the professionals in occupational health influence/approach policy decisions of the future when it comes to CO2 emission regulations, fossil fuel usage, farming protocols, benefits for green companies, consequences for polluters, the awarding of research funding, fracking, accountability for damages, etc.
Brief overview of suggested approach, solution, or research question: I suggest an approach where we focus on the health consequences of regional climate change and reinforce them with the financial costs. For example, climate advocates have been saying (for decades) that temperatures will rise worldwide and we will see an increase in the severity, duration, and frequency of extreme weather events. The consequences of a worldwide rise in temperature do not mean much to the average individual where climate change is negligible so they will not care about climate change. We have to focus on regions and specific problems (like Southern California’s drought or India’s heat wave) to personalize climate change effects, while monetizing them to enlighten the general public, the government, and the private sector as to how much they have lost in the past and how much they will lose in the future if the appropriate actions are not taken. Hopefully, this approach will allow occupational health professionals to receive more influence in making decisions for current and future laws, regulations, and taxes.
University of Washington, Environmental and Occupational Health, PhD student
Problem Statement: Workers are seldom limited to a single occupational exposure yet in occupational health we primarily seek to understand occupational exposures individually. While as a field we are beginning to incorporate multiple chemical exposures, these tend to be of the same type of chemical such as organophosphate pesticides, and not take into account other simultaneous exposures. Simultaneous exposures through separate pathways may affect a common physiologic mechanism contributing to the development of a chronic health condition. For example, heat stress, high noise exposure, and pm2.5 exposure are each associated with myocardial infarction and development of ischemic heart disease but these common co-exposures are rarely sampled concurrently. Sampling only one of these exposures underestimates the risk to the worker and disassociates the cumulative occupational exposures to the worker from their impact on total worker health.
Brief Overview of Suggested Approach: To better understand the exposures leading to the development of chronic health conditions, understand how the social determinants of health interact with occupational health, and further develop Total Worker Health, we must develop methods to measure multiple exposures and integrate the results. Sampling equipment should be designed to be more flexible, be used alongside other equipment, and for ease of combining data with those from other systems. New techniques are needed to properly combine exposure data and create more accurate estimates of risk.
Tongii University, Director of Department of Occupational and Environmental Medicine, School of Medicine, Shanghai, PRC
Problem statement: Long term occupational work exposure to high concentration of benzene will likely cause occupational benzene poisoning. Different countries have entirely different diagnostic criteria for benzene poisoning, possibly related to scientific recognition, race distribution, economic status as well as many other reasons.
Brief overview of suggested approach, solution, or research question: In 2014, our hospital had a case from Taipei, where the patient had been working in a printing and manufacturing factory in mainland China for over past 4 years, mainly comes into contact with ink and benzene, dimethylbenzene, acetic ester and so on. The patient started experiencing dizziness, headache, fatigue and insomnia after two years of work, with lowered platelet counts, the lowest PLT 24×109/L, and highest 59×109/L, with an average of 7.8×109/L. We have eliminated differential diagnosis through blood system disease, and whether the patient should be diagnosed as occupational benzene poisoning is controversial. According to Taiwanese diagnostic criteria, the patient does not quality, but simply looking at the platelet decrease as one of the diagnostic index of the criteria in mainland china, the patient would quality. Therefore, the question to be contemplated here is how to solve the problem of imbalance in diagnostic standards from difference regions. As the global economic development and increasing immigrating population, occupational health and its globalization awareness should therefore be raised.
Joseph Robert Cammarata
Washington University St. Louis Health Care Management Undergraduate Student
Washington University St. Louis Department of Orthopedic Surgery, Workers’ Compensation Coordinator
Problem statement: Worker/ employer level injury prevention education in small companies (50 workers or less) is largely ignored or at best, quickly brushed over by both parties resulting in frequent worker injuries and employers who do know proper protocols. The workers and employers lack the depth of education needed to facilitate fewer work injuries and manage injuries if they occur.
Brief overview of suggested approach, solution, or research question: I propose an in-depth work injury education pilot program focusing on proper work injury prevention and management for both the workers and employers of four small companies. All four small companies will be in the same county (to keep travel to a minimum for the pilot trainer) and will be from different industries to bring a broad spectrum of age, education level, gender, race, ethnic background, socioeconomic level, and injury type. The trainer will have experience on both sides of this issue (worker as well as employer) and an extensive background in work injury prevention, management, protocols, and workers’ compensation state regulation. The education will focus on two main areas; work injury prevention and injury management. The injury prevention portion will train the worker and employer about a pre-workday together worker/ employer 15 minute stretch period exposed to sunlight (if weather permits). The injury management portion will train the worker and employer about what to do if an injury occurs. This will include how to report, who to report to, what paper work is needed, time frames, how to get authorization, where to get treatment, how to follow up, how a workers’ compensation claim is reported, and the rights of the worker and employer.
Future of Occupational Health: Research
Colorado State University Industrial Hygiene PhD student
Problem statement: New low-cost sensors for evaluating aerosols are being developed at a rapid pace with the aim to improve our understanding of what’s in the air around us. Most of these low-cost devices lack the precision and accuracy of the gold standard devices they are replacing. However, the developers of this devices hope that the low cost nature of these devices will increase temporal evaluation of aerosol exposures in the workplace.
Brief overview of suggested approach, solution, or research question: I suggest that research should be conducted to develop a new tier of regulations based on data taken from low-cost aerosol monitoring. The data taken by low-cost aerosol monitors shouldn’t be discounted, but appropriate statistical methods need to be utilized to account for the potentially lower accuracy and precision of low-cost aerosol monitors. Such policy would permit the use of low-cost aerosol monitors which could provide the opportunity for improved temporal sampling and thus provide better insight into aerosolized occupational exposures.
University of Texas School of Public Health, Department of Epidemiology, Human Genetics and Environmental Sciences, PhD Candidate
Problem statement: Preterm birth and being born small-for-gestational age (SGA) are major contributors to infant mortality and morbidity in the U.S. Despite the clinical importance of preterm birth and SGA, there are few established modifiable risk factors for these adverse birth outcomes and prevention strategies to reduce the public health burden of these adverse birth outcomes are lacking. Maternal occupational exposures such as heavy lifting have been suggested as potential risk factors for preterm birth and SGA. Occupational exposures are particular importance as there has been a dramatic increase (>20%) in the prevalence of employed pregnant women during the last several decades, and the majority (~90%) of pregnant women remain employed during pregnancy.
Brief overview of suggested approach, solution, or research question: Despite increasing epidemiological literature on certain work activities and adverse birth outcomes, the role of many domains of occupational physical activities (e.g., bending) and emotional stressors (e.g., dealing with unpleasant or angry people) on adverse birth outcomes remains unknown. Therefore, we examined the association between a wide range of maternal occupational physical activities and emotional stressors in each trimester of pregnancy and preterm birth and SGA. Findings from such studies will 1) help women of reproductive age in various occupations to decrease their risk of adverse birth outcomes and 2) inform employers to better accommodate pregnant workers from potentially hazardous occupational activities.
Amanda K. Marshall
Southwest Center for Occupational and Environmental Health, University of Texas Health Science Center, Houston, School of Public Health Occupational Epidemiology Doctoral Trainee
Problem statement: Unconventional oil and gas extraction is a rapidly expanding sector of the petroleum industry. There are many sources of potential threats to the health and safety of the population of workers in the industry, however, data regarding exposures and responses is scant and access for primary data collection is extremely challenging.
Brief overview of suggested approach, solution, or research question: In order to best provide for the health and safety of unconventional oil and gas extraction workers, both industry and academics must seek to better understand the full nature of occupational exposures as well as human responses to these exposures. This industry, in particular, is prone to high turnover, boom and bust cycles, shift work, isolated work sites, and other factors that result in significant barriers to research and intervention development. Some potential areas of exploration include lung function before and after work tours and measurements of particulate and silica exposures while on the job. I suggest that it is of paramount importance to build and sustain partnerships with industry that will enable academia to gain access to this population in order to generate beneficial research and interventions. The conundrum to be solved lies in how to garner trust among industry employers (i.e. drilling contractors) that leads to collaborative efforts on behalf of the employee.
CAREX Canada, Occupational Exposures Lead
Simon Fraser University, PhD student
Problem statement: Graduate level occupational hygiene training in Canada has been designed with both research and practical career trajectories in mind, but this has actually had the effect of doing neither to a high standard. In the research realm, it is increasingly difficult to find quality candidates to fill open positions due to a lack of practical research experience (including study design, data management and statistical analysis skills, and knowledge translation/communications).
Brief overview of suggested approach, solution, or research question: A core set of courses that enable masters-level graduates to become successful hygienists is key, but tailoring of electives and practicum-like experiences that differed based on whether a candidate was geared towards research or professional practice could increase employability in both areas of practice. It is not enough to focus this training at the PhD level; there are many positions that Canadian occupational epidemiologists need masters-level graduates to undertake that shouldn’t require a PhD. In particular, the skills that I see as lacking in research-minded masters graduates are practical data management and communication and knowledge translation skills. More tailored programs for masters students could increase their ability to get hired, no matter their career trajectory.
University of British Columbia, School of Population and Public Health, PhD Student
Problem statement: Non-regular daytime work (shiftwork) has been linked to numerous health and safety outcomes. Despite being relatively common in North America, policies and workplace interventions aimed at mitigating the negative effects of shiftwork have been slow to develop. This may be due to: 1) The wide variability in shiftwork structures (e.g., shift duration, shift rotation, time of day worked), and 2) A limited understanding of what drives this variability at the workplace level.
Brief overview of suggested approach, solution, or research question: Is shiftwork truly a soup of unpredictable characteristics (as some have claimed), or is it possible to link particular shiftwork structures with industry- and workplace-level characteristics? A study currently underway in British Columbia aims to address this question, by describing shiftwork structures across industry sectors in the province, and assessing whether organization-level factors can be used to predict "more healthy” or “less healthy” shiftwork structures. We believe that a better understanding of shiftwork' variability will promote stronger health evidence. Just as importantly, identifying predictors of this variability will support targeted recommendations for workplace and policy interventions.
Katie M. Applebaum, PhD
George Washington University, Milken Institute School of Public Health, Assistant Professor
Problem statement: A report in Morbidity and Mortality Weekly Report (2008) indicated that deaths due to environmental heat exposure increased over time (total of n=423 deaths, 1992-2006). However, heat-related outcomes, including mortality are not widely studied in the U.S. Further, research is impeded by underreporting of heat-related deaths and a lack of systematic reporting of other occupational heat-related events.
Brief overview of suggested approach, solution, or research question: I’d like to have an open discussion around methodological limitations in studying heat-related outcomes. For example, in studying heat-related deaths, are death certificates and/or International Classification of Disease codes somehow currently insufficient to capture heat-related deaths? Some research shows that input from a third party is important in determining this classification (e.g., a co-worker needing to inform doctor that the subject was exposed to hot conditions). How can we best study non-fatal heat-related outcomes (e.g., heat stress, heat stroke) given that these events may not be reported routinely? Given the misclassification of these events, what study designs would be preferred to study these outcomes?
Mary E. Miller, RN, MN
Child Labor Specialist (Formerly with Washington State Department of Labor and Industries)
Problem statement: Over recent decades, research on working youth has focused on describing acute injuries and health effects from hazards of work exposures or unsafe conditions. Several areas have received little to no attention, such as ergonomic risk factors and musculoskeletal disorders that may occur during early work experiences; or the long-term impacts of early work experience injuries. In addition, limited attention has focused on the psychosocial impacts of the work many youth experience, in particular the impacts of work intensity (i.e., long work hours) and late-night shifts; bullying by managers or co-workers; or threats from hostile customers, etc. Research in this area is virtually non-existent in the United States and in recent years, increased pressure has emerged to limit the restrictions place in youth employment in favor of developing a “work ethic”.
Brief overview of suggested approach, solution, or research question: This discussion will examine psychological functioning and social/intellectual development issues for children and adolescents and the health risks of work which have rarely been addressed researchers and policy makers. An overview of the types of working conditions that may pose the greatest psychosocial hazards to children and youth will be discussed. A discussion of the research needs and possible tools and guidelines for assessing these impacts which have been employed outside of the US will be summarized and suggestions for research priorities will be provided.
University of Washington, Department of Health Services, PhD Candidate
Problem statement: The amount of older workers in the US is expected to rise in terms of percent and raw numbers, from 18.2 million in 2000 to 31.9 million in 2025. Older workers have lower injury rates relative to younger workers, but their injuries are more serious, costly, require more time off, and they are less likely to return to work. Improving our understanding of the association between injury risk and physical, sensory, and cognitive health will assist in creating injury prevention initiatives.
Brief overview of suggested approach, solution, or research question: I will examine how occupational injury risk among older workers is impacted by health, cognition, hearing, sight, job demands, and age. My analysis informs how job demands and workers’ ability to meet those demands, based on their health and understanding of said demands, impact risk of occupational injury. Job demands will be assessed according to the worker’s assessment and the job description. By modeling the interaction between a health state (e.g. eyesight) and a job demand (e.g. job requires good eyesight), I will test the hypothesis that injury risk increases if job demands cannot be met. The study is a retrospective secondary analysis of a longitudinal survey. The analysis uses a GEE model with robust standard errors, clustered on the individual level to account for repeated observations. Data comes from the Health and Retirement Survey, a biennial survey on adults age 50 and above.
Future of Occupational Health: Policy
Garrett Brown, MPH, CIH
California Division of Occupational Safety and Health (Cal/OSHA), Retired
Problem statement: In 1970, a conservative Republican President signed into law the federal OSHA Act establishing the federal and state OHSA agencies. In 2015, it is unlikely that the sitting Democratic President would receive such an Act, or even sign it if it reached his desk, and rulemaking activities by OSHA have ground to a halt in Washington. The current Democratic Governor of California put the state’s OSHA program on a “starvation diet,” in terms of funding and staffing, during his first term that weakened enforcement and worker protections in the nation’s “premier state plan.” How can workplace health and safety agencies regain the political support and the financial and human resources they need to effectively protect workers through regulatory enforcement in the 21st century economy?
Brief overview of suggested approach, solution, or research question: The reason that Richard Nixon signed the OSHA Act was the political pressure and momentum generated by a social movement led by labor unions and OHS professionals that made reducing workplace injuries, illnesses and fatalities a priority for both political parties. Supporters of effective regulatory enforcement – as part of a comprehensive OHS approach involving research, advocacy and enforcement – need to rebuild the coalition that won the 1970 Act by engaging with unions interested in OHS issues, publicizing the economic and human costs of unsafe workplaces, and highlighting the impact of lax enforcement on particularly vulnerable populations such as immigrant workers, temporary or contingent workers, “invisible” agricultural and service sector workers, as well as traditional high-risk sectors like construction, health care and manufacturing.
Maria Korre, MS
Harvard T.H. Chan School of Public Health, Occupational Medicine Sc.D Candidate
Problem Statement: The American Workplace is in the midst of an unrelenting epidemic of obesity and cardio metabolic risk. Considering that a typical adult consumes about one third of his/her total daily food intake while at work, efforts should be made to improve dietary habits in the workplace. Mediterranean diets (MDs) are closely associated with benefits on cardiovascular disease (CVD) risk factors such as obesity, hypertension, diabetes mellitus, and metabolic syndrome. The latest US nutritional guidelines also recognize the MD as one of three recommended healthy options for Americans.
Brief overview of suggested approach, solution, or research question: While limited workplace data is available, it supports benefits from workplace interventions, and further large clinical trials are needed to develop the most appropriate dietary strategies and interventions in the workplace, such as modifying food selection, eating patterns, meal frequency, and the sourcing of meals taken during work. Given the wealth of evidence supporting the MD and its potential cardio protective role, future emphasis on the role of MD in the workplace is likely to be a promising strategy to improve metabolic and cardiovascular health outcomes. We need to motivate individuals within their occupational setting to incorporate Mediterranean Diet principles through education, participation and incentives. Workplaces can promote healthy eating among employees by providing nutritious foods in the company cafeteria, in the vending machines, and at worksite functions. There is also suggestive evidence that MD workplace interventions are cost-effective, while the reduction in workers’ compensation and disability will reduce considerably.
Nicholas K. Reul, MD, MPH
Associate Medical Director for Occupational Disease, Washington State Department of Labor and Industries
Problem Statement: Industrial insurance has been a key element of United States occupational health public health infrastructure for over one hundred years, predating expectations of universal personal health insurance coverage that have encouraged passage of legislation such as the Affordable Care Act. The extent to which the cost of work-related injuries and illnesses are borne by employers provides price signals that incentivize socially desirable goals of improving the safety and health of America’s workplaces, preventing disability, supporting return to work, and restoring lost function among those recovering from injuries and illnesses related to employment.
Brief overview of suggested approach, solution, or research question: Such outcomes are also important beyond the population of individuals with claims for workers’ compensation. Whether an individual’s disability is caused by a work-related exposure or not, the workplace is often a vital consideration for recovery. The quality of life and economic implications of America’s occupational health figure importantly in the substantial policy challenges posed by the costs of healthcare and disability compensation in the United States. The experience and interventions adopted by workers’ compensation systems—such as in Washington—in the practice of secondary and tertiary disability prevention promises to confer benefits to occupational health that all society may benefit from, irrespective of compensability through workers’ compensation. To this end, strategic coordination and information sharing between the stewards of workers’ compensation systems with general healthcare policymakers and researchers would promote the public welfare as the United States continues toward universal access to healthcare, and is consistent with ACA mandates that included developing “a national prevention, health promotion, public health, and integrative health care strategy that incorporate the most effective and achievable means of improving the health status of Americans and reducing the incidence of preventable illness and disability.”
University of California, San Diego Human Biology / Public Health B.S / B.S. Undergraduate student
Problem statement: Because immigrants do not have a legal status in the United States, there are no policies that aid those that get injured while working.
Brief overview of suggested approach, solution, or research question: I suggest a variety of approaches to target this problem because there are many aspects to consider. The first thing I suggest doing is approaching the political side of the situation. There needs to be adequate funding to the cause as well as attention from the policy makers in regards to the issue at hand. The second target population should be the immigrants themselves, providing them education on the rights that they deserve as employees in the United States. This will be a lengthy process that would take many years to implicate, but the end result would benefit the United States as a whole. Potential revenue from healthcare and adequate safety will be available for the workers with an immigrant status.
Katie M. Applebaum, PhD
George Washington University, Milken Institute School of Public Health, Assistant Professor
Problem statement: Thousands of workers are sickened annually due to occupational heat exposure. With predictions of rising global temperatures, we can expect an increase in heat-related events at work. The Occupational Safety and Health Administration (OSHA) offers resources to workers and employers regarding heat exposure (e.g., Heat Smartphone App, Wet Bulb Globe Thermometer, fact sheets, prevention recommendations). The information available through OSHA may be helpful to workers in understanding their rights in preventing heat-related illnesses. But is it reaching them?
Brief overview of suggested approach, solution, or research question: Of the material available through OSHA, it appears that the workers are most likely to see the fliers, potentially posted by an employer, describing how to recognize heat-related illnesses and prevent them. Some of the fliers also describe what the company should provide, for example: access to cool, shaded rest areas, require workers to take rest periods which should increase during hotter days, and provide cool water. It would be beneficial to conduct a survey of workers in high-risk industries listed on the OSHA website (e.g., agriculture, baggage screeners, military) to see what messages are reaching them and to evaluate whether the materials are being distributed to high-risk workers and the effectiveness of the materials in fostering workplaces that prevent heat-related illnesses.