*2.2. COMPASS Adaptation and Pilot for the OHCC*

During the development and research phases for COMPASS investigators solicited union and OHCC input, provided regular updates to the OHCC training committee and the union to inform them of progress and findings, and periodically discussed the future of the program. Following the successful RCT, and in response to ongoing dialogue about the program, the OHCC requested that investigators adapt COMPASS to be offered as a paid training course in their system. One motivation for this decision expressed by OHCC leaders was an interest in cultivating leadership skills among HCWs. A plan for adapting COMPASS guidebook one was worked out collaboratively, implemented by researchers, and then pilot tested. Adjustments to the approach were guided by OHCC practical needs, but with a commitment to retaining core evidence-based tactics. Adjustments included: a faster cycle time, where groups met every other week instead of once a month; reduction of total meetings to seven (e.g., only topics from guidebook one); the use of professional OHCC-contracted trainers to serve as group facilitators who would lead the first meeting and then support each group as a "guide on the side" thereafter; using rotating volunteer peer-leaders at meetings two through seven; removing the meal served during breaks; replacing some original group and individual goals to attend related OHCC trainings with new goals focused on workers making targeted work-environment and behavior changes; and incentive adjustments. The long-term strategic plan also included proposed adjustments to training evaluation questions for all OHCC training courses in order to accommodate a peer-led course series like COMPASS. Table 1 summarizes COMPASS guidebook one original topics and goals, as well as adaptations (most adaptations were made prior to the adaptation pilot, but some were made afterward).

The adaptation pilot involved five COMPASS groups led by four OHCC facilitators in three Oregon cities. This sampling approach was selected to provide a check that the adjusted process was functional across multiple facilitators and groups, and that the intervention was changing targeted outcomes by a similar magnitude (effect size) relative to the effective version evaluated in the RCT. Workers received hourly wages for attending COMPASS adaptation pilot meetings, just as they would for attending other courses offered by the OHCC (workers receive wages for any non-duplicated course annually). Pilot participants received an additional \$15 for completing surveys and/or taking part in an interview with study staff. Plans were also made for COMPASS to satisfy safety training requirements (completion of two safety courses every two years) for workers to be listed on the OHCC registry for finding (or being found by) potential new Medicaid/Medicare-funded consumer-employers. The adapted program was supported with the same ergonomic toolkit and resource giveaways as the intervention as implemented in the RCT. However, no incentives were provided for individual or group certification. Instead, printed paper certificates were awarded based on attendance. As noted above, professional trainers under contract with the OHCC were identified to serve as COMPASS facilitators. The research team created a half-day orientation and facilitator training workshop to prepare facilitators for their role. This training included a history of the program and research findings, description and handouts on the role of facilitators, and practice with scripted guidebook activities with coaching from researchers. Guidebooks and other materials for implementation were provided to facilitators before their first group meeting.




**Table 1.** *Cont.*

poster with the image of a house with doors and windows to track group and individual goal completion. In the adapted version of COMPASS the poster was not used due to removal the certification incentives (a simple attendance requirement for getting COMPASS safety class credits was instituted instead). The PRAISE mnemonic was created by Dr. Robert Wright, and stood for: Plan, Respect, Ask open ended questions, use "I" statements, and Express empathy.

of

At baseline researchers collected direct measures of height (SECA 213 stadiometer; SECA, Chino, CA, USA) and weight (Tanita TBF-310GS; Tanita Corp, Arlington Heights, IL, USA), and survey measures of demographics, work history, and current work characteristics. Pre- and post-program evaluation measures emphasized outcomes from the prior RCT [10]. Survey scales/items included experienced community of practice [29]; frequency counts for five types of safety behaviors [10]; fruit and vegetable consumption (single item 1–10+ servings daily, created for adaptation pilot); consumption of sugary drinks, snacks, and fast food meals [30]; frequency of meals brought from home [30]; weekly healthy physical activity levels [26]; and physical and psychological well-being [31].

#### *2.3. Statewide Rollout of COMPASS in the OHCC Training System*

In parallel with and following the adaptation pilot test, several efforts were initiated to support eventual adoption and statewide rollout of COMPASS within the OHCC's training system. These efforts included initiating negotiations for an interagency agreement between Oregon Health & Science University (OHSU) and the Oregon Department of Human Services to govern the terms of use of guidebooks; investigators requesting adjustments to the standard OHCC training evaluation questions to accommodate a course series like COMPASS; and revisions to the OHCC version of the COMPASS guidebook in response to observing the pilot and in response to guidance from OHSU Technology Transfer and Business Development. We also explored whether other stakeholders, such as the relevant workers' compensation insurer or an SEIU Health Trust, would support or fund parts of the dissemination effort. These conversations did not result in direct financial support for dissemination efforts, but helped guide sustainability decisions and resulted in in the addition of information about an Employee Assistance Program available to HCWs to the Extras section of COMPASS guidebooks.

Negotiations for terms of use of the program took quite a long time, in part due to the timing of the retirement of the OHCC's Training Director and other staff turnover. Other hurdles involved navigating unclear review and approval steps within the state government, and some long inter-agency response times for document review requests. At the conclusion of over a year of episodic back-and-forth work and hand-offs on the inter-agency research agreement, the ultimate terms granted the OHCC non-exclusive rights to print and use COMPASS guidebooks in exchange for sharing long-term evaluation data with OHSU (5+ years). Evaluation data would include class attendance for COMPASS and non-COMPASS courses, class evaluations, and assisting OHSU in coordinating with the workers' compensation insurer to obtain injury claims data for workers who took COMPASS over the years and cross-sectional comparison groups of workers who either had not taken any training, and those who had taken some training classes (but not COMPASS).

Within the OHCC training system, at the end of each class HCWs are asked to complete a training evaluation (no names recorded) and leave it for their trainer to collect. Some of these original evaluation items did not clearly apply to a peer-led and scripted program. For example, one item asked workers to rate the degree to which "Information was presented in a variety of ways to facilitate learning." In COMPASS, all of the material is presented using a single scripted and peer-led method, and past research showed that this method produced large knowledge gains [22]. Two additional items asked students to rate the trainer's performance (preparedness and communication effectiveness), but in COMPASS, there is a supporting facilitator rather than a traditional trainer. In addition to recommending adjustments to questions like those above, researchers also requested additional questions that asked workers to rate their intentions to make changes as a result of the training.

To further strengthen the program and streamline dissemination, COMPASS guidebooks were further adjusted in ways to support their use in the OHCC training system. Giveaways for students that had no funding stream within the state (or potential funding stream) to support their use in the OHCC version of COMPASS, and homework assignments facilitated with such giveaways (e.g., small knee pads), were removed from the program. Investigators also replaced some activities with new ones, and made adjustments to other activities to make them run more smoothly. With guidance from

OHSU Technology Transfer and Business Development, investigators also worked with an OHSU graphic design specialist to create a professional design and layout for the guidebooks.

After the agreement was settled and signed, and the revised OHCC guidebooks with the new design were ready, the OHCC and investigators planned a "soft launch" of COMPASS by two facilitators in two cities. One facilitator had participated in the original adaptation pilot, and the other was new to the COMPASS program. The new facilitator and other OHCC staff received in-person training from investigators regarding COMPASS group facilitation, and the facilitator with previous experience had a meeting with investigators to be refreshed on the program and be informed of changes and adjustments made. Following the soft launch further technical corrections were made to the guidebooks (fixing typos, clarifying arrangements) and we removed all remaining giveaways for students and replaced them with alternatives (e.g., step counter giveaways used for walking challenges were removed, and activities/goals were altered to focus on "walking minutes per day/week"). As of October 2018, 2 additional facilitators were trained by OHCC training department staff and 12 groups have been completed or initiated in 7 different cities.

#### **3. Results**

#### *3.1. Adaptation Pilot Results*

Four facilitators (*n* = 3 female) were recommended by the OHCC Training Director and trained by investigators for the adaption pilot. Forty-two home care workers registered for five COMPASS groups (one facilitator ran two groups) offered in the following cities: Albany (*k* = 2), Salem (*k* = 2), and Corvallis (*k* = 1). The groups were offered at varied times to maximize opportunities for workers, with one in the late morning, three in the early afternoon, and one in the evening.

Participants were predominantly older (mean age = 49.23 years), female (80.56%), and Caucasian (77.78%). Workers reported an average tenure in home care of 7.12 years and an average of 22.37 weekly work hours. The reported lifetime prevalence of a diagnosis of depression or anxiety was 41.67% and 44.44%, respectively. For additional demographic details please see Table 2.


**Table 2.** Home care worker participants in the pilot study of the COMPASS adaptation for the Oregon Home Care Commission: Characteristics at baseline.

**Table 2.** *Cont.*


Note: OHCC = Oregon Home Care Commission. <sup>a</sup> This sample size represents workers who enrolled at baseline and returned for post-intervention measurements. When percentages are reported they reflect the percent of those reporting for that variable. <sup>b</sup> The survey failed to provide an option for participants to select "single", or to set a time frame for the recency of divorce or separation status. <sup>c</sup> An outlier data point of 78 reported current public consumer-employers was removed for analysis of this variable due to the improbability that such a number could be correct. <sup>d</sup> 3 did not report yes or no for medication. <sup>e</sup> 1 did not report yes or no for medication. <sup>f</sup> 1 did not report yes or no for medication.

Changes in primary outcomes were evaluated with descriptive effect sizes (Cohen's *d*) and two-tailed *t* tests. Given that the pilot was designed to evaluate feasibility and check effect sizes, and not to be a fully statistically powered effectiveness study, inferential *t*-test results should be viewed as supplementary and interpreted with the understanding that type II errors were probable. Pre- and post-program means, mean changes, effect sizes, and *p* values are reported in Table 3. Moderate-to-large effect sizes and statistically significant changes were observed for experienced community of practice, using new tools/techniques for housecleaning, fruit and vegetable consumption, meals brought from home, and healthy physical activity. All other outcomes changed in expected directions with the exception of two safety outcomes that had very small negative effect sizes (<0.10).


**Table 3.** COMPASS adaptation pilot intervention effects on primary outcomes.

Note: Sample size varied due to missing responses for certain questions. Cohen's *d* effect sizes were computed using the pooled standard deviation for pre and post-test time points. *p*-values are for two tailed *t*-tests. CE = Consumer-employer. SF-12 = 12-item short form health survey. <sup>a</sup> Sum of nine items rated on a five-point scale, responses range from 1 (strongly disagree) to 5 (strongly agree). <sup>b</sup> Six-point frequency scales, responses ranged from 0 (never) to 5 (5+ times). <sup>c</sup> Items related to sugary snacks, drinks, fast food, and meals from home were reported on 10 frequency intervals: 1, never | 2, 1–3 times per month | 3, 1–2 times per week | 4, 3–4 times per week | 5, 5–6 times per week | 6, Once per day | 7, 2 times per day | 8, 3 times per day | 9, 4 times per day | 10, 5 or more times per day. Thus, a mean score of 3 would equal the behavior occurring 1–2 times per week. <sup>d</sup> Mean of four items asking about days per week with 30 min of different moderate-to-vigorous physical activities. Eight-point response scale ranged from 0 (none) to 7 (daily).
