Health risk assessment
A health risk assessment (also referred to as a health risk appraisal and health & well-being assessment) is one of the most widely used screening tools in the field of health promotion and is often the first step in multi-component health promotion programs.
A health risk assessment (HRA) is a health questionnaire, used to provide individuals with an evaluation of their health risks and quality of life. Commonly a HRA incorporates three key elements – an extended questionnaire, a risk calculation or score, and some form of feedback i.e. face-to-face with a health advisor or an automatic online report.
The Centers for Disease Control and Prevention define a HRA as: “a systematic approach to collecting information from individuals that identifies risk factors, provides individualised feedback, and links the person with at least one intervention to promote health, sustain function and/or prevent disease.” 
There is a range of different HRAs available for adults and children. Some target specific populations. For example, in the US, Medicare HRAs ask seniors about their ability to perform daily activities. Medicaid assessments ask questions about health-care access, availability of food, and living conditions. Most HRAs capture information relating to:
- Demographic characteristics – age, sex
- Lifestyle – exercise, smoking, alcohol intake, diet
- Personal and family medical history (in the US, due to the current interpretation of the Genetic Information Non-discrimination Act, questions regarding family medical history are not permitted if there is any incentive attached to taking a HRA)
- Physiological data – weight, height, blood pressure, cholesterol
- Attitudes and willingness to change behaviour in order to improve health
The main objectives of a HRA are to:
- Assess health status
- Estimate the level of health risk
- Inform and provide feedback to participants to motivate behaviour change to reduce health risks
In the US, HRAs used as part of the Medicare Annual Wellness Visit help identify issues important to a senior’s health and well-being. HRAs used as part of Medicaid enrollment help identify individuals with health problems that need immediate attention.
The original concept of the HRA can be traced back to the decision by the assistant Surgeon General of the United States to conduct a study to determine probable 10-year lifespan of individuals based on lifestyles and predisposed conditions. The project, led by Lewis C. Robbins, MD, of the Public Health Service, was the Framingham study. The study was based on in-depth longitudinal studies of 5,000 families in Framingham, Massachusetts, that continues to this day under funding from the National Institutes of Health. Dr. Robbins left the Public Health Service and joined Methodist Hospital in Indianapolis where, working with Jack Hall, MD, he developed the first set of health hazard tables. This culminated in the publication of How to Practice Prospective Medicine in 1970 – a guide for practising physicians, which outlined the health risk assessment questionnaire, risk computations and patient feedback strategies. It wasn't until 1980, when the Centers for Disease Control and Prevention released a publicly available version, that the HRA became widely used, particularly in workplace settings. Health & Welfare Canada reviewed How to Practice Prospective Medicine and created a mainframe version of the book. The Centers for Disease Control became aware of this product and adapted it to the newly available personal computer. When Prudential Life Insurance also took an interest and asked to fund an update of the program, the CDC, which could not accept private project funding at the time, transferred ownership to the Carter Center at Emory University where it was updated from 1986-7. The transfer and subsequent program were managed by Dr. Ed Hutchins who had worked on the HRA in positions at the University of Pennsylvania and Charlotte-Mecklenberg Hospital. At Charlotte Mecklenberg, he secured a contract with the World Health Organization to create a mainframe product that could be used on an international basis. The HRA was managed as a not-for-profit product. Copies were distributed to every state health department and liaisons were assigned to each to work with their staffs to evaluate related data. Over 2,000 copies of the software were distributed to users who requested it and approximately 70 copies of the code were provided to for-profit companies that were interested in developing proprietary products. This proliferation coincided with the rapid growth in interest in corporate health promotion programs as awareness developed on health risks and for-profit vendors monetized the programs. The Carter Center's interest shifted to Africa and Dr. Hutchins founded the Healthier People Network (HPN) which in 1991 to continue the work. HPN raised funds to support the HRA but additional funding was not forthcoming from government sources. As a result, the Carter Center and HPN could not underwrite basic supporting activities such as annual conferences and, over time, the State-based liaison network and associated intellectual capital atrophied as programs lost funding and liaisons moved on. The use of HRAs and corporate wellness programs has been most prevalent in the United States, with comparatively slower growth elsewhere. However there has been recent strong growth in corporate wellness outside the US, particularly in Europe and Asia.
Once an individual completes a HRA, they usually receive a report, detailing their health rating or score, often broken down into specific sub scores and areas such as stress, nutrition and fitness. The report can also provide recommendations on how individuals can reduce their health risks by changing their lifestye.
In addition to individual feedback, HRAs are also used to provide aggregated data reporting for employers and organizations. These reports include demographic data of participants, highlight health risk areas and often include cost projections and savings in terms of increased healthcare, absence and productivity. Organization-level reports can then be used to provide a first step by which organizations can target and monitor appropriate health interventions within their workforce.
The delivery of HRAs has changed over the years in conjunction with advances in technology. Initially distributed as paper-based, self-scoring questionnaires through on-site workplace health promotion sessions, HRAs are now most commonly implemented online. Other delivery methods include telephone, mail and face-to-face.
The advantages of online HRAs include:
- Tailoring – online HRAs can adapt content based on an individual’s answers to the HRA questionnaire to provide a personalised, relevant and interactive user experience.
- Improved data management
- Reduced administrative costs
- Instant feedback
Extensive research has shown that HRAs can be used effectively to:
- Identify health risk factors.
- Predict health-related costs
- Measure absenteeism and presenteeism
- Evaluate the efficacy and return on investment of health promotion strategies 
However, it is generally accepted that HRAs are most effective at promoting behavior change when they form part of an integrated, multi-component health promotion program. Applied in this way, the HRA is used primarily as a tool to identify health risks within a population and then target health interventions and behavior change programs to address these areas.
The Wellness Councils of America (WELCOA) outlines 10 key benefits of conducting personal health risk assessments. Health risk assessments:
- Provide employees with a snapshot of their current health status.
- Enable individuals to monitor their health status over time.
- Provide employees with concrete information thus preparing them for lifestyle change.
- Help individuals get involved with health coaching.
- Provide important information concerning employees' readiness to change.
- Help employers measure and monitor population health status.
- Provide employers with important information that can help them build results-oriented health promotion programmes.
- Can provide employers with important information on productivity.
- Allow employers to evaluate changes in health behaviour and health risks over time.
- Engage both employers and employees in the health management process.
The limitations of a HRA are largely related to its usage and it is important to recognise that a HRA highlights health risks but does not diagnose disease and should not replace consultation with a medical or health practitioner.
There are reportedly over 50 different HRA providers in the market, offering a variety of versions and formats. Major vendors with National Committee for Quality Assurance (NCQA) Wellness and Health Promotion (WHP) Certification or Health Information Products (HIP) Certification include PDHI, Wellsource, eDoc4U, HealthFitness, Health Media, vielife, Healthways, HealthCheck360, OptumHealth and WebMD. A global health risk assessment provided by InfoTech's Wellness Checkpoint adapts to the language, culture and regional evidence based guidelines to provide global key performance indicators aligning health with business risk management. In India Truworth wellness collects information from individuals in a systematic manner and evaluates their health risks as well as quality of life.
- Yen L, McDonald T, Hirschland D, Edington DW (October 2003). "Association between wellness score from a health risk appraisal and prospective medical claims costs". Journal of Occupational and Environmental Medicine 45 (10): 1049–57. doi:10.1097/01.jom.0000088875.85321.b9. PMID 14534445.
- Gazmararian JA, Foxman B, Yen LT, Morgenstern H, Edington DW (October 1991). "Comparing the predictive accuracy of health risk appraisal: the Centers for Disease Control versus Carter Center program". American Journal of Public Health 81 (10): 1296–301. doi:10.2105/AJPH.81.10.1296. PMC 1405330. PMID 1656798.
- Alexander G (2000). "Health risk appraisal" (PDF). The International Electronic Journal of Health Education 3 (Special): 133–137.
- Baker K, DeJoy D, and Wilson M. Using online health risk assessments, The Journal of Employee Assistance. April 2007.
- Centers for Disease Control and Prevention. Health Risk Appraisals, Visited 9 October 2009.
- Warshaw, L. Chapter 15: Health risk appraisal, International Labour Organization’s Encyclopaedia of Occupational Health and Safety 4th ed. 1998
- Centers for Medicare & Medicaid Services. "Preventive visit & yearly wellness exams.".
- Center for Medicaid and CHIP Services and Centers for Medicare & Medicaid Services. "Core Set of Children’s Health Care Quality Measures for Medicaid and CHIP (Child Core Set)" (PDF).
- Schoenbach VJ (April 1987). "Appraising health risk appraisal". American Journal of Public Health 77 (4): 409–11. doi:10.2105/AJPH.77.4.409. PMC 1646957. PMID 3826457.
- Mills PR (2005). "The development of a new corporate specific health risk measurement instrument, and its use in investigating the relationship between health and well-being and employee productivity". Environmental Health 4 (1): 1. doi:10.1186/1476-069X-4-1. PMC 548523. PMID 15679885.
- Working well: A global survey of health promotion and workplace wellness strategies (PDF). Buck Consultants. October 2008.[page needed]
- Yen L, Schultz A, Schnueringer E, Edington DW (September 2006). "Financial costs due to excess health risks among active employees of a utility company". Journal of Occupational and Environmental Medicine 48 (9): 896–905. doi:10.1097/01.jom.0000235987.75368.d0. PMID 16966956.
- Anderson DR, Whitmer RW, Goetzel RZ et al. (2000). "The relationship between modifiable health risks and group-level health care expenditures. Health Enhancement Research Organization (HERO) Research Committee". American Journal of Health Promotion 15 (1): 45–52. doi:10.4278/0890-1171-15.1.45. PMID 11184118.
- Burton WN, Chen CY, Conti DJ, Schultz AB, Edington DW (August 2003). "Measuring the relationship between employees' health risk factors and corporate pharmaceutical expenditures". Journal of Occupational and Environmental Medicine 45 (8): 793–802. doi:10.1097/01.jom.0000079090.95532.db. PMID 12915781.
- Boles M, Pelletier B, Lynch W (July 2004). "The relationship between health risks and work productivity". Journal of Occupational and Environmental Medicine 46 (7): 737–45. doi:10.1097/01.jom.0000131830.45744.97. PMID 15247814.
- Loeppke R, Taitel M, Richling D et al. (July 2007). "Health and productivity as a business strategy". Journal of Occupational and Environmental Medicine 49 (7): 712–21. doi:10.1097/JOM.0b013e318133a4be. PMID 17622843.
- Mills PR, Kessler RC, Cooper J, Sullivan S (2007). "Impact of a health promotion program on employee health risks and work productivity". American Journal of Health Promotion 22 (1): 45–53. doi:10.4278/0890-1171-22.1.45. PMID 17894263.
- Burton WN, Chen CY, Conti DJ, Schultz AB, Edington DW (March 2006). "The association between health risk change and presenteeism change". Journal of Occupational and Environmental Medicine 48 (3): 252–63. doi:10.1097/01.jom.0000201563.18108.af. PMID 16531829.
- Ozminkowski RJ, Dunn RL, Goetzel RZ, Cantor RI, Murnane J, Harrison M (1999). "A return on investment evaluation of the Citibank, N.A., health management program". American Journal of Health Promotion 14 (1): 31–43. doi:10.4278/0890-1171-14.1.31. PMID 10621522.
- Ozminkowski RJ, Goetzel RZ, Wang F et al. (November 2006). "The savings gained from participation in health promotion programs for Medicare beneficiaries". Journal of Occupational and Environmental Medicine 48 (11): 1125–32. doi:10.1097/01.jom.0000240709.01860.8a. PMID 17099448.
- Anderson DR, Staufacker MJ (1996). "The impact of worksite-based health risk appraisal on health-related outcomes: a review of the literature". American Journal of Health Promotion 10 (6): 499–508. doi:10.4278/0890-1171-10.6.499. PMID 10163313.
- WELCOA Special Report. 2008. The 10 Benefits of Conducting a Personal Health Assessment., Visited 9 October 2009.
- National Committee for Quality Assurance. "Wellness & Health Promotion Report Card".
- National Committee of Quality Assurance. Health Information Products (HIP) Certification, Thursday 1 October 2009. Visited 9 October 2009.