Worksite: Assessment of Health Risks with Feedback (AHRF) to Change Employees’ Health – AHRF Plus Health Education With or Without Other Interventions
Findings and Recommendations
The Community Preventive Services Task Force (CPSTF) recommends the use of assessments of health risks with feedback when combined with health education programs, with or without additional interventions, on the basis of strong evidence of effectiveness in improving one or more health behaviors or conditions in populations of workers. Additionally, the CPSTF recommends the use of assessments of health risks with feedback when combined with health education programs to improve the following outcomes among participants:
- Tobacco use (strong evidence of effectiveness)
- Excessive alcohol use (sufficient evidence of effectiveness)
- Seat belt use (sufficient evidence of effectiveness)
- Dietary fat intake (strong evidence of effectiveness)
- Blood pressure (strong evidence of effectiveness)
- Cholesterol (strong evidence of effectiveness)
- Number of days lost from work due to illness or disability (strong evidence of effectiveness)
- Healthcare services use (sufficient evidence of effectiveness)
- Summary health risk estimates (sufficient evidence of effectiveness)
The CPSTF finds insufficient evidence for:
- Body composition
- Consumption of fruit and vegetables
- Fitness
The CPSTF found insufficient evidence for assessments of health risks with feedback when implemented alone.
The full CPSTF Finding and Rationale Statement and supporting documents for Worksite: Assessment of Health Risks with Feedback (AHRF) to Change Employees’ Health — AHRF Plus Health Education With or Without Other Interventions are available in The Community Guide Collection on CDC Stacks.
Intervention
This intervention includes:
- An assessment of personal health habits and risk factors (may be used with biomedical measurements of physiologic health)
- A quantitative estimation or qualitative assessment of future risk of death and other adverse health outcomes
- Provision of feedback in the form of educational messages and counseling describing how changing one or more behavioral risk factors might change the risk of disease or death
Worksite interventions may use assessment of health risks with feedback (AHRF) alone or as part of a broader worksite health promotion program that includes health education and other health promotion components.
About The Systematic Review
The CPSTF finding is based on evidence from a systematic review of 51 studies (search period through June 2005).
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.
- Intervention were conducted in variety of worksites including manufacturing plants, healthcare facilities, health insurance companies, government offices, field settings, banks, schools, and ambulance service
- Most studies were in companies with more than 500 employees and in urban or suburban settings; 6 in medium-sized companies (50-499 employees), 1 in small company (50 employees)
- 40 studies in U.S., 2 in European countries, 2 each in Australia and Finland, 1 each in Canada, Japan, Netherlands, Sweden, and Switzerland
- Whites and African Americans were well represented among studies reporting race
- Average age of participants: 40 years, range of educational levels and job positions
- Almost all interventions included health education lasting more than 1 hour or occurring at more than one time
- Health education provided in group settings, one-on-one, or both
- Some interventions also provided enhanced access to physical activity (17), nutrition (6), and medical care (3)
- About one-third offered some form of incentive or competition
Summary of Results
Fifty-one studies qualified for the review.
Health Behavior Outcomes
- Excessive alcohol use (9 studies): majority of results favorable; moderate decreases in risky drinking behaviors and amount consumed
- Dietary behavior (14 studies): changes favorable except one study showing no change in fruits and vegetables. Fruits/vegetables: median increase of 0.09 servings/day (6 studies). High risk fat intake: median relative decrease of 5.4% (13 studies)
- Physical activity (18 studies): majority favorable. Percent physically active: median relative increase of 15.3% (16 study arms)
- Seatbelt use (10 studies): all but one finding favorable. Percent not using seatbelts all the time: median relative decrease of 27.6%
- Tobacco use (29 studies): all results favorable. Prevalence: median relative decrease of 13.3% (27 study arms). Cessation rates: 17.8% (21 study arms)
Physiologic Indicators
- Blood pressure (31 studies): results favorable. Diastolic: median decrease of 1.8 mm Hg (22 study arms). Systolic: median decrease of 2.6 mm Hg (24 study arms). High risk prevalence: median decrease of 4.5 percentage points (16 study arms)
- Body composition (27 studies): some results favorable, some not. Body weight: median decrease of 0.56 pounds (17 study arms). BMI: median decrease of 0.50 points
- Cholesterol(27 studies): results favorable. Total cholesterol: median decrease of 4.8 mg/dL (23 study arms). HDL: median increase of 0.94 mg/dL (10 study arms). High risk prevalence: decrease of 6.6 percentage points (12 study arms)
- Fitness (6 studies): results favorable but effect estimates small and difficult to interpret (6 studies)
Other Variables
- Risk status: results favorable; effect estimate moderate (16 studies)
- Healthcare service use: direction mixed as outcomes varied; majority favorable; effect estimates generally moderate (6 studies)
- Absenteeism: results favorable; effect estimate moderate (10 studies)
Summary of Economic Evidence
Nine studies qualified. Monetary values in 2005 U.S. dollars.
- Program costs per participant per year: $65 to $285 (7 studies); per employee per year: $40 to $234 (2 studies)
- Program benefits per participant per year: $93 to $695 (7 studies); per employee per year: $160 to $272 (2 studies)
- Benefit-to-cost ratio: 1.4:1 to 4.6:1, meaning every dollar invested yielded annual gain between $1.40 and $4.60 (8 studies)
Applicability
Results applicable to programs implemented in small, medium, or large companies in a range of settings. Whites and African Americans were well represented; insufficient information to determine differential effects for different racial or ethnic groups.
Evidence Gaps
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.
Implementation Considerations and Resources
- Employers may be reluctant to implement interventions involving AHRF due to employee concerns over breach of confidentiality to other employees or health insurance providers.
- Programs offering incentives for completion or requiring specific health standards may exacerbate concerns.
- Engaging employees can be challenging. Those who think or know they have important health risks may be least likely to participate.
- Even with broad participation in AHRF, there may be low participation in additional intervention components. Employers may be inclined to reduce scope of or cancel these components.
- Potential harms include increased anxiety for workers during feedback; false positives; and overestimates of risk status.
Crosswalks
Healthy People 2030 includes the following objectives related to this CPSTF recommendation.