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Worksite: Assessment of Health Risks with Feedback (AHRF) to Change Employees' Health – AHRF Plus Health Education With or Without Other Interventions

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What the Task Force Found

About The Systematic Review

The Task Force finding is based on evidence from a systematic review of 51 studies (search period through June 2005). The review was conducted on behalf of the Task Force by a team of specialists in systematic review methods, and in research, practice, and policy related to worksite health promotion.

Context

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Summary of Results

Fifty-one studies qualified for the review.

  • This review considered a range of outcome measures for each outcome category. Conclusions for each of these outcomes are based on a review of both quantified and qualitatively described results.

Health Behavior Outcomes

  • Excessive Alcohol Use
    • Nine studies qualified for the review.
      • The majority of study results were in favor of the intervention.
      • There were moderate decreases in prevalence rates of risky drinking behaviors and amount of alcohol consumed.
  • Dietary Behavior
    • Fourteen studies qualified for the review.
      • With the exception of one study that showed no change in intake of fruits and vegetables, changes in dietary behaviors were in favor of the intervention.
      • Intake of fruits and vegetables: median increase of 0.09 servings per day (6 studies)
      • Percent of employees with high risk fat intake: median relative decrease of 5.4% (interquartile interval: -21.9% to -1.8%; 13 studies)
  • Physical Activity
    • Eighteen studies qualified for the review.
      • The majority of results were in favor of the intervention.
      • Percent of employees who were physically active: median relative increase of 15.3% (interquartile interval: 8.3% to 37.2%; 16 study arms)
  • Seatbelt Use (percent of directly observed use, percent of self-report use)
    • Ten studies qualified for the review.
      • All but one finding were in favor of the intervention.
      • Percent of employees not using seatbelts all of the time: median relative decrease of 27.6% (interquartile interval: –56.4% to –7.4%; 10 studies)
  • Tobacco Use
    • Twenty-nine studies qualified for the review.
      • All results were in favor of the intervention.
      • Prevalence rates (percent of employees who smoke): median relative decrease of 13.3% (interquartile interval: –24.0% to –3.3%; 27 study arms)
      • Cessation rates (percent of employees who quit):17.8% (interquartile interval: 12.0% to 22.6%; 21 study arms)

Physiologic Indicators

  • Blood Pressure
    • Thirty-one studies qualified for the review.
      • Results were in favor of the intervention.
      • Diastolic blood pressure: median decrease of 1.8 mm Hg (interquartile interval: –4.4 to –0.3 mm Hg; 22 study arms)
      • Systolic blood pressure: median decrease of 2.6 mm Hg (interquartile interval: –4.8 to –0.3 mm Hg; 24 study arms)
      • Change in prevalence rate of employees with high risk blood pressure reading: median decrease of 4.5 percentage points (interquartile interval: –8.7 to –0.4 percentage points; 16 study arms)
  • Body Composition (weight, body mass index [BMI] or percent body fat)
    • Twenty-seven studies qualified for the review.
      • Some of the results were in favor of the intervention and some were not.
      • Change in body weight: median decrease of 0.56 pounds (interquartile interval: –5.1 to +1.5 pounds; 17 study arms)
      • Change in BMI: median decrease of 0.50 points (interquartile interval: –1.1 to –0.3 points BMI)
  • Cholesterol
    • Twenty-seven studies qualified for the review
      • Results were in favor of the intervention.
      • Total cholesterol: median decrease of 4.8 mg/dL (interquartile interval: –10.4 to 0.0 mg/dL; 23 study arms)
      • HDL cholesterol: median increase of 0.94 mg/dL (interquartile interval: –0.9 to 2.3 mg/dL; 10 study arms)
      • Percent of employees with high risk readings: decrease of 6.6 percentage points (interquartile interval: –14.8 to –2.4 percentage points; 12 study arms)
  • Fitness (aerobic capacity, heart rate after a stepping exercise or Astrand Rhyming test for sub-maximal fitness)
    • Six studies qualified for the review.
      • Results were in favor of the intervention.
      • Effect estimates were small and difficult to interpret.

Other Variables

  • Risk Status (health risk score, appraised age, healthy lifestyle or % employees in a high-risk category)
    • Sixteen studies qualified for the review.
      • Results were in favor of the intervention.
      • The size of the effect estimate was moderate.
  • Healthcare Service Use
    • Six studies qualified for the review.
      • The direction of the results was mixed as reported outcomes varied across studies.
      • While indicators varied by study, the majority of results were in favor of the intervention and effect estimates were generally of moderate size.
  • Absenteeism
    • Ten studies qualified for the review.
      • Results were in favor of the intervention.
      • The size of the effect estimate was moderate.

Summary of Economic Evidence

Nine studies qualified for the economic review. All monetary values are reported in 2005 U.S. dollars.

  • Program costs
    • Costs per participant per year ranged from $65 to $285 (7 studies).
    • Costs for per employee per year ranged from $40 to $234 (2 studies).
  • Program benefits
    • Benefits per participant per year ranged from $93 to $695 (7 studies).
    • Benefits per employee per year ranged from $160 to $272 (2 studies).
  • The benefit-to-cost ratio—defined as averted medical costs, productivity losses due to the program as both, divided by program costs—ranged from 1.4:1 to 4.6:1. This means that every dollar invested into the intervention yielded an annual gain between $1.40 and $4.60 (8 studies).

Applicability

  • Results from this review should be applicable to programs implemented in small, medium, or large companies in a range of settings.
  • Whites and African Americans were well represented among studies reporting information on race; however, there was not enough information available to determine if the intervention had differential effects for different racial or ethnic groups.

Evidence Gaps

Each Community Preventive Services Task Force (Task Force) review identifies critical evidence gaps—areas where information is lacking. Evidence gaps can exist whether or not a recommendation is made. In cases when the Task Force finds insufficient evidence to determine whether an intervention strategy works, evidence gaps encourage researchers and program evaluators to conduct more effectiveness studies. When the Task Force recommends an intervention, evidence gaps highlight missing information that would help users determine if the intervention could meet their particular needs. For example, evidence may be needed to determine where the intervention will work, with which populations, how much it will cost to implement, whether it will provide adequate return on investment, or how users should structure or deliver the intervention to ensure effectiveness. Finally, evidence may be missing for outcomes different from those on which the Task Force recommendation is based.

Identified Research Gaps

The following outlines evidence gaps for assessment of health risks with feedback when used alone, and when combined with health education programs, with or without additional interventions.

This review of the use of assessments of health risks with feedback in worksite settings addressed important questions that earlier reviews were unable to address, such as:

  • Does AHRF, when used alone, lead to behavior change or change in health outcomes among employees?
  • Does this type of assessment, when used with other worksite-based intervention components result in change?
  • And finally, what types of behaviors or health outcomes are affected by these interventions?

The structure of this review, however, leaves two additional questions about worksite health promotion programs unanswered:

  • Are worksite health promotion programs with a health education component effective in the absence of AHRF and
  • Does AHRF add value to worksite health promotion programs with regards to behavior change and improvement in health outcomes?

The field will also likely be interested in addressing questions related to implementation of the intervention: what components are necessary and for whom are they most effective? How many times must AHRF occur and for how long must employees be exposed to additional intervention components? What qualifications of staff or health educators are needed? How long do the effects last? With regards to the assessment: Are there key assessment questions or aspects of the assessment (like biometric screening) that provide information resulting in a more effective intervention? Does the format of the questionnaire or the feedback make a difference? Is employee participation in creation of the program important and what role does organizational support play in participation rates and overall effectiveness?

Finally, questions regarding economic efficiency will be of interest to most in the field and should be addressed more systematically. A first step would be to clearly delineate the aspects of program costs and benefits that should be assessed in program evaluation. How many employees need to be reached for a positive ROI? What should the GRP (gross rating product) be for the ROI? Is there a “break even point” or a certain amount of time for which costs will outweigh benefits before there are actual savings from program implementation? Although the questions above stem from this review of assessments of health risk with feedback, many of them pertain to the broader field of worksite health promotion and can be used to inform future evaluation of these programs.

Study Characteristics

  • Of the 51 studies included in the AHRF Plus review:
    • Twenty studies included an untreated or lesser treated comparison group.
    • Five studies used a retrospective cohort.
    • Four studies were a time series study.
    • Twenty-two studies were included as before-after study designs.
  • Evaluated interventions were conducted in a variety of worksites including manufacturing plants, healthcare facilities, health insurance companies, government offices, field settings, banks, schools, and in an ambulance service workforce.
  • Most studies were conducted in companies or worksites with more than 500 employees and in urban or suburban settings.
  • Six studies were conducted in medium-sized companies (50 –499 employees) and one in a small company (50 employees).
  • Forty studies were conducted in the U.S., two in a group of European countries, two each in Australia and Finland, and one study was conducted in each of the following countries: Canada, Japan, the Netherlands, Sweden, and Switzerland.
  • Whites and African Americans were well represented among studies reporting information on race.
  • The average age of participants was 40 years, and a range of educational levels and job positions was represented.
  • Almost all of the evaluated interventions included health education lasting more than 1 hour or occurring at more than one time during the course of the intervention.
  • Health education was provided in group settings, one-on-one, or both.
  • Some of the evaluated interventions also provided enhanced access to physical activity (17 programs), nutrition (6 programs), and medical care (3 programs).
  • About one-third of the interventions offered some form of incentive or competition for participating or for meeting a program goal.

Publications