*2.2. Intervention Design*

Based on the researchers' criteria, the company's regional director for health and safety recommended five skilled nursing facilities that did not yet have active HP programs and whose administrators were expected to be receptive to the participatory intervention process. We selected three of these facilities using a priori criteria to judge which were most organizationally ready for PIP [32]. Another three facilities with pre-existing, corporate-initiated HP programs were recommended by the regional director as control (NPHP) sites on the basis of their current activities and administrator commitment to the program [32].

In the PIP centers, team members were recruited from the entire workforce from volunteers responding to posters and management promotion of the program. Each team started with employees from various departments (clinical, dietary, housekeeping, laundry, maintenance, office/business) who met bi-weekly for one hour with two researchers. Initial team meetings involved identification of key issues in workplace health, psychosocial stress, and work organization.

The intervention began with intensive orientation of the PIP team (2–4 meetings per site over 1–2 months) to worker health and well-being, and Total Worker Health as a comprehensive approach. PIP teams identified issues of importance to members and discussed possible solutions or projects to address these concerns. Team members sought the opinions of their co-workers for program goals and specific activities. PIP team members communicated with individuals at various levels of their facility with updates and available activities (Figure 2).

Initially the researchers facilitated meetings, guided discussions, and assisted in framing presentations to the site administrator regarding a team's proposed project. Active facilitation involved the wellness champion and a research assistant attending all bi-weekly team meetings over 2 to 3 years, followed by monthly team meetings over 1 to 2 years, then quarterly telephone check about the program process with the wellness champion per site. The researchers provided technical assistance on a variety of topics, such as seminars on ergonomics in skilled nursing facilities and a food preferences survey to assist in developing programs for healthier food provision. Meeting minutes and activity logs were maintained by the researchers and utilized for ongoing process evaluation.

The goal was that participatory teams would move over time from co-governance to become independent, with support of the facility wellness champion. Thus, the study plan called for the researchers gradually to reduce our facilitation efforts over time. This was communicated to all participants at the beginning of the project. The phase-out period entailed 1–2 years of quarterly telephone check-ins with the wellness champion.


**Figure 1.** Timeline of the participatory intervention process and impact evaluation. HP, health promotion; PIP, participatory intervention program; CPH-NEW, CenterforthePromotionofHealthintheNewEnglandWorkplace.

**Figure 2.** Participatory Intervention Design within Centers.

#### *2.3. Data Collection and Analysis*

A mixed-method (convergent parallel strategy) approach utilized qualitative and quantitative data to examine the process and impact of the participatory OSH/HP or NPHP program in each facility. Results from the qualitative and quantitative analyses were triangulated with the researchers' direct experiences and knowledge of the organization to understand the process, impact, and sustainability of the participatory program.

Quantitative data included a brief baseline (pre-intervention) survey of the wellness champions about HP program activities in all six centers. We also conducted employee surveys in the six centers at baseline (2008–2009) and around the fourth year (2012–2013) of the participatory intervention. A self-administered questionnaire collected information on worker chronic disease history, health beliefs and behaviors, and perception of the work environment: physical and psychological job demands, decision latitude, and social support from supervisors and coworkers [8,33,34]. Work environment items included physical exertion, safety climate, psychological demands, decision latitude, and supervisor and coworker support. Psychological demands (two items), decision latitude (two items), physical exertion (five items), and supervisor (two items) and coworker support (two items) were selected from the Job Content Questionnaire (JCQ) [35]. The JCQ subscales have demonstrated good validity and acceptable internal consistency in large study populations from six countries [35]. Safety climate was measured with two items from Griffin and Neal [36] and two items developed by the investigators.

Most analyses compared employees in the pooled intervention (PIP) group to the pooled control (NPHP) group (three centers per group). Baseline (*n* = 645) and post-intervention (*n* = 649) prevalences were compared by cross-tabulation with chi-square statistics and mean values by t-test for independent samples. Cumulative incidence of self-reported chronic diseases was computed from baseline to post-intervention within each group and compared between PIP and NPHP with Fisher exact tests due to small numbers. Within-person changes from baseline to follow-up (limited to workers responding to both surveys) were examined using stratified cross-tabulation and paired sample t-test. All analyses were done with SPSS 22.0 (IBM SPSS, Chicago IL, USA).

Qualitative data included the meeting minutes and activity logs collected throughout the active facilitation period. Follow-up data were collected 3–4 years after the intervention began (2011–2012). Data types included: (1) focus groups with team members; (2) focus groups with other nursing home employees; (3) in-depth interviews with individual team members and wellness champions; (4) in-depth interviews with management (administrators and directors of nursing); and (5) in-depth interviews with supervisors (department heads and unit/office managers) [24].

Other evaluation materials included researchers' field notes on observed indoor spaces (employee lounge, break room, vending machines, and bulletin boards), outdoor spaces (employee picnic areas and gardens), and printed materials (employee newsletters, flyers, and informational literature) devoted to HP, OSH, or related activities or information. Researcher experiences and observations were logged after each field visit and consulted for purposes of this evaluation. Content analysis was performed using NVivo 9.0 software on transcripts from interviews and focus groups. We compared the themes that emerged across and within the six sites, focusing on (1) integration of HP and OSH, (2) comparative effects of the PIP and NPHP programs, and (3) sustainability of PIP as a model.

Metrics for comparison and evaluation included:

