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 Community Preventive Services Task Force (CPSTF) recommends the use of HRAs in workplace settings when used in combination with health education, having found there is strong or satisfactory evidence that they help improve the following behaviors among employees:
- Consuming too much alcohol
- Seat belts
- Fat consumption
- Blood pressure
- Healthcare services use
- Summary health risk estimates
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. During the 1960s, some researchers in California formed the Human Population Laboratory (HPL) to investigate factors contributing to quality of life. Inspired by a research article reporting on the HPL's Alameda County Study on the best lifestyle practices for good health, Don R. Hall, DrPH, developed a Health Age Assessment algorithm on a calculator while a masters student at Loma Linda University in 1972. In 1977, Dr. Don Hall coded his longevity calculations on a TRS-80, creating the first computerized health risk assessment. Within a year, he had programmed 12 health assessments on single topics such as nutrition, fitness, weight, and stress. In 1979, when personal desktop computers became readily available, he packaged all 12 assessments together on a floppy disk and marketed it as a comprehensive health risk assessment. 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 lifestyle.
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 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 generally have National Committee for Quality Assurance (NCQA) Wellness and Health Promotion (WHP) Certification or Health Information Products (HIP) Certification.
- 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.[permanent dead link]
- Community Preventive Services Task Force (February 2007). "Worksite: Assessment of Health Risks with Feedback (AHRF) to Change Employees' Health – AHRF Plus Health Education With or Without Other Interventions".
- Baker K, DeJoy D, and Wilson M. Using online health risk assessments, The Journal of Employee Assistance. April 2007.
- "Redirect Page". www.cdc.gov.
- Warshaw, L. Chapter 15: Health risk appraisal Archived 7 April 2011 at the Wayback Machine, International Labour Organization’s Encyclopaedia of Occupational Health and Safety 4th ed. 1998
- Centers for Medicare & Medicaid Services. "Preventive visit & yearly wellness exams".[permanent dead link]
- 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). Archived from the original (PDF) on 8 February 2015. Retrieved 13 February 2015. Cite uses deprecated parameter
- Soler, Robin; et al; the Task Force on Community Preventive Services (2010). "A Systematic Review of Selected Interventions for Worksite Health Promotion: The Assessment of Health Risks with Feedback" (PDF). American Journal of Preventive Medicine. 38(2S): S237–S262 – via Elsevier Science Direct.
- 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.
- Housman, Jeff; Dorman, Steve (2005). "The Alameda County Study: a Systematic, Chronological Review" (PDF). The American Journal of Health Education. 36 (5): 302–308. doi:10.1080/19325037.2005.10608200 – via ERIC.
- Belloc, Nedra; Breslow, Lester (August 1972). "Relationship of physical health status and health practices". Preventive Medicine. 1 (3): 409–421. doi:10.1016/0091-7435(72)90014-X.
- "Commencement program" (PDF). home.llu.edu. 2019. Retrieved 9 July 2019.
- "Don-Hall". Wellsource.
- 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. Archived from the original (PDF) on 16 August 2009. Retrieved 28 October 2009. Cite uses deprecated parameter
- 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.
- National Committee for Quality Assurance. "Wellness & Health Promotion Report Card".[permanent dead link]