**4. Discussion**

This study evaluated a participatory, integrated OSH/HP intervention in three skilled nursing facilities compared to three others with more traditional, non-participatory HP programs. Mixed qualitative and quantitative data collected over a four-year follow-up period demonstrated program feasibility, good process fidelity while the researchers were actively involved, meaningfulness of the integration concept to worker representatives, and moderate program impact on some organizational conditions of work. Sustainability, however, suffered due to lack of resources and inconsistent manager support.

#### *4.1. Process Fidelity*

Process fidelity was high initially in all three intervention sites; the program was introduced in a uniform manner by the researchers and proceeded as intended for the first two years or so. Members of the PIP teams were highly motivated and responsive to the organizing principles of worker priority-setting and a combined focus on both work and non-work obstacles to health. The center

administrators permitted front-line staff to volunteer for the teams and assisted with the logistics of scheduling meetings, although use of paid work time for meetings was inconsistent. Involvement of non-supervisory clinical employees in the planning of workplace HP projects was high in the PIP centers at the start of the research project, although it diminished subsequently.

#### *4.2. Integration*

Compared to the traditional wellness programs in the control sites, the participatory teams in the three PIP centers were far more likely to develop activities with a broad scope, encompassing elements of both OSH and HP. Over time, the teams in the PIP centers addressed work organization, psychosocial stressors, physical ergonomics, in addition to taking an organizational approach to HP goals such as improving the food environment at work. In contrast, the NPHP centers primarily supported individual behavior change, with minimal attention to psychosocial stressors or the work environment. Consistent with our findings, a previous intervention study reported higher blue-collar worker participation with OSH/HP interventions compared to standard HP interventions [16]. In particular, when management's efforts to reduce workplace hazards were apparent, the workers were more likely to participate [16]. In our study, administrative changes and logistical challenges appeared to cause worker participation in the teams to dwindle gradually.

#### *4.3. Impact*

The number and variety of workplace HP activities initiated during the study period were higher in the PIP centers than the NPHP centers. Two of the three PIP centers indicated improvement in organizational factors. There were no larger corporate influences that would have produced these positive changes specifically in the three PIP centers, so it seems reasonable to consider them at least partially as outcomes of the integrated participatory program.

There was no evidence of major change in chronic illness incidence or the perception of health status or behaviors following this participatory intervention, but the four-year follow-up period was too short for any such difference to be expected.

The study hypothesis was that the PIP teams would have more impact than the NPHP programs. In a participatory approach, employees are actively engaged in problem identification, decision making, implementation, and evaluation of the program [38]. This approach has been argued to benefit intervention effectiveness because employees are well-qualified to identify opportunities and obstacles present in their work environment [25], and also because participating in intervention design and implementation could reduce perceived lack of decision latitude [9,39]. Intervention study with assembly workers has demonstrated improved health and work performance in the participatory group compared to controls [40]. While there is substantial literature on participatory workplace interventions, the literature is more consistent about short-term and process benefits than longer-term ones. It remains challenging to compile the evidence in such a way as to identify patterns that explain differences in impact.

#### *4.4. Sustainability*

Overall leadership support is widely recognized as crucial factors for a sustainable workforce health program of any type [16,32,41] and were so endorsed in the qualitative interviews in our study. Two PIP centers exhibited positive indicators with the participatory approach including essential factors such as support from the center that favored the continuation of meetings and activities.

Unfortunately, the initially high level of administrator supports and staff participation in project planning diminished somewhat over time. One of our goals was to incorporate the teams into other active committees with similar interests, in order to increase their long-term sustainability. In the two centers where this occurred, the teams were absorbed into committees without responsibility for employee health.

Administrator changes also negatively impacted management support, financial resources, and time release for program participation—all identified as important for progress of the participatory program [32]. Challenges to long-term PIP sustainability included communication barriers among employees, especially in different units, shifts, and job groups; excessive reliance on individual program champions at both site and regional levels; inconsistent corporate commitment to employee HP; and lack of a reward system for champions' or administrators' efforts. These mostly pre-dated the participatory teams, although we had sought to screen centers for favorable conditions.

All six centers lacked financial resources to sustain even basic wellness programs, such as paying for instructors in yoga, meditation, or fitness. It did not appear that employee health (other than safe resident handling, which had received a substantial investment) was perceived to generate a high enough return on investment to be sustained in this company.
