**1. Introduction**

Internationally, construction workers have higher rates of musculoskeletal disorders, and chronic diseases related to obesity, lack of physical activity and smoking than workers in other industries [1–4]. In construction workers, musculoskeletal disorders have a one-year pain prevalence rate (at least one

episode of pain in the last year) of 51% for the back, 37% for the lower extremities, 32% for the upper extremities, and 24% for the neck in construction workers [5]. The high prevalence of musculoskeletal and cardiovascular disorders causes a sizable burden to employers, insurers, and society as a whole, attributing to work absenteeism, healthcare costs, work schedule delays, and high turnover [6–8]. In 2014, approximately 33% of absenteeism was attributed to musculoskeletal symptoms [9].

Construction workers also have high rates of chronic health issues. Over 70% of construction workers are overweight [10]. Obese construction workers are at increased risk of receiving disability benefits for cardiovascular disease and musculoskeletal disorders [11,12]. This risk is even higher for obese workers with high physical job demands, especially for those with musculoskeletal disorders [11]. Specifically, construction workers also have the highest prevalence of smoking (39%) of all occupational groups [1]. The risk of chronic lung disease and cancers is also amplified by the combined effects of smoking with other respiratory exposures, such as dust, silica, and asbestos [13–15].

Extensive research has linked these injury and poor health outcomes to individual factors, as well as the conditions of work, including job demands, physical work environment and psychosocial work factors (e.g., supervisor support and worker collegiality) [7]. Construction workers' injuries and poor health have been associated with the high physical demands, prolonged exposure to awkward postures, whole body vibration, long working hours, and psychosocial hazards in the work environment [2,16].

While these factors are prevalent in the construction industry, the complex work organization of construction work provides additional challenges for implementing traditional workplace prevention programs. The hierarchical structure between the site owners, general contractors, and subcontracting companies results in a fissured workplace [17]. The dynamic nature of these worksites results in workers moving on and off the site day-to-day. In addition, construction has high workforce turnover within the company, further complicating the number of workers transitioning in and out of the workforce, which has been linked to higher injury rates [18,19].

Integrated approaches that address the work environment to improve both occupational safety and health outcomes, and worker wellbeing outcomes, are acknowledged as being the most successful [20,21]. However, these integrated and comprehensive interventions for construction worksites need further investigation [20–25]. To date, most integrated approaches for construction workers have been individual-based, or those provided through labor unions [24,26]. Many worksite-based safety interventions for construction worksites have focused on using simple campaigns (such as poster and leaflet educational material) [27,28], training programs [29,30], behavioral management programs [10,31,32], or new, task-specific ergonomic tools and methods [33,34]. The intervention, "All the Right Moves" (ARM) described in this study, tested a different approach based on integrated approaches promoted by The National Institute for Occupational Safety and Health (NIOSH) Total Worker Health*®* program. Such approaches target the conditions of work that affect workers injuries and health outcomes [7,35]. The ARM intervention targeted the conditions of work through a worksite-based ergonomics program integrated into current work practices and on-site opportunities for workers to improve their health behaviors. The project's goal was to develop and determine the feasibility of an integrated health promotion and health protection worksite-based program designed specifically for the dynamic nature of a commercial construction work site.

The purpose of this study was to examine the intervention—ARM, on commercial construction sites, using a mixed methods approach. The specific aims of this project were to examine the efficacy of an integrated program including: (1) a soft tissue injury prevention program on workers' perception of worksite ergonomic practices, new pain and injury incidences, and work limitations; and (2) a health promotion/health coaching (Health Week) program for diet, leisure time physical activity, and reduced smoking behaviors.
