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

The CPST 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 CPSTF by a team of specialists in systematic review methods, and in research, practice, and policy related to worksite health promotion.

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.

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).

• 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.

CPSTF identified several areas that have limited information. Additional research and evaluation could help answer the following questions and fill remaining gaps in the evidence base. (What are evidence 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.

• 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.

Soler E, Leeks KD, Razi S, et al. A systematic review of selected interventions for worksite health promotion: the assessment of health risks with feedback. American Journal of Preventive Medicine 2010;38(2S):237-262.

Task Force on Community Services. Recommendations for worksite-based interventions to improve workers’ health. American Journal of Preventive Medicine 2010;38(2S):232-236.

Fielding JE, Hopkins DP, Pronk NP. An introduction to evidence on worksite health promotion. In: ACSM’s Worksite Health Handbook: A Guide to Building Healthy and Productive Companies. 2nd ed. Champaign (IL): Human Kinetics; 2009:75-81. Available at: http://www.humankinetics.com/products/all-products/acsms-worksite-health-handbook-2nd-edition.

Soler RE, Griffith M, Hopkins DP, Leeks KD, Pronk NP. The assessment of health risks with feedback: results of a systematic review. In: ACSM’s Worksite Health Handbook: A Guide to Building Healthy and Productive Companies. 2nd ed. Champaign (IL): Human Kinetics; 2009:75-81. Available at: http://www.humankinetics.com/products/all-products/acsms-worksite-health-handbook-2nd-edition.

Effectiveness Review

Analytic Framework see Figure 1 on page S241

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

Effectiveness Review

Summary Evidence Table

The number of studies and publications do not always correspond (e.g., a publication may include several studies or one study may be explained in several publications).

Effectiveness Review

Aldana SG, Greenlaw R, Diehl HA, Englert H, Jackson R. Impact of the Coronary Health Improvement Project (CHIP) on several employee populations. Journal of Occupational and Environmental Medicine 2002;44:831-9.

Aldana SG, Jacobson BH, Harris CJ, Kelley PL. Mobile work site health promotion programs can reduce selected employee health risks. Journal of Occupational Medicine 1993;35:922-8.

Aldana SG, Jacobson BH, Kelley PL, Quirk M. The effectiveness of a mobile worksite health promotion program in lowering employee health risk. American Journal of Health Promotion1994;8:254-6.

Anderson J, Dusenbury L. Worksite cholesterol and nutrition: An intervention project in Colorado. American Association of Occupational Health Nurses Journal 1999;47: 99-106.

Anderson RC, Anderson KE. Positive changes and worksite health education. Psychological Reports 1994;74:607-10.

Baier CA, Grodzin CJ, Port JD, Leksas L, Tancredi DJ. Coronary risk factor behavior change in hospital personnel following a screening program. American Journal of Preventive Medicine1992;8:115-22.

Bertera RL. Behavioral risk factor and illness day changes with workplace health promotion: two-year results. American Journal of Health Promotion 1993;7:365-73.

Blair SN, Piserchia PV, Wilbur CS, Crowder JH. A public health intervention model for work-site health promotion. Impact on exercise and physical fitness in a health promotion plan after 24 months. JAMA 1986;255:921-6.

Bly JL, Jones RC, Richardson JE, Bly JL, Jones RC, Richardson JE. Impact of worksite health promotion on health care costs and utilization. Evaluation of Johnson & Johnson’s Live for Life program. JAMA 1986;256:3235-40.

Breslow L, Fielding J, Herrman AA, Wilbur CS. Worksite health promotion: its evolution and the Johnson & Johnson experience. Preventive Medicine 1990;19:13-21.

Brill PA, Kohl HW, Rogers T, Collingwood TR, Sterling CL, Blair SN. Relationship between sociodemographic characteristics and recruitment, retention, and health improvements in a worksite health promotion program. American Journal of Health Promotion 1991;5:215-21.

Donnelly IW. Using health promotion to improve workers’ health. Managing Employee Health Benefits 1996:74-7.

Dunton S, Perkins DD, Zopf KJ. The impact of worksite-based health risk appraisal programs on observed safety belt use. Health Education Research 1990;5:207-16.

Edington M, Karjalainen T, Hirschland D, Edington D. The UAW-GM Health Promotion Program: Successful Outcomes. American Association of Occupational Health Nurses Journal2002;50:26-31.

Edye BV, Mandryk JA, Frommer MS, Healey S, Ferguson DA. Evaluation of a worksite programme for the modification of cardiovascular risk factors. Medical Journal of Australia1989;150:574-81.

Erfurt JC, Foote A, Heirich MA. Worksite wellness programs: incremental comparison of screening and referral alone, health education, follow-up counseling, and plant organization.American Journal of Health Promotion 1991;5:438-48.

Erfurt JC, Holtyn K. Health promotion in small business: What works and what doesn’t work.Journal of Occupational Medicine 1991;33:66-73.

Fielding JE, Knight K, Mason T, Klesges RC, Pelletier KR. Evaluation of the IMPACT blood pressure program. Journal of Occupational Medicine 1994;36:743-6.

Fitzgerald ST, Gibbens S, Agnew J. Evaluation of referral completion after a workplace cholesterol screening program. American Journal of Preventive Medicine 1991;7:335-40.

Frommer MS, Mandryk JA, Edye BV, Healey S, Berry G, Ferguson DA. A randomised controlled trial of counseling in a workplace setting for coronary heart disease risk factor modification: effects on blood pressure. Asia Pacific Journal of Public Health 1990;4:25-33.

Goetzel RZ, Dunn RL, Ozminkowski RJ, Satin K, Whitehead DA, Cahill K. Differences between descriptive and multivariate estimates of the impact of Chevron Corporation’s Health Quest program on medical expenditures. Journal of Occupational & Environmental Medicine1998:40(6):538-45.

Goetzel RZ, Kahr TY, Aldana SG, Kenny GM. An evaluation of Duke University’s live for life health promotion program and its impact on employee health. American Journal of Health Promotion 1996;10.

Goetzel RZ, Ozminkowski RJ, Bruno JA, RutterKR, Isaac F, Wang S. The long-term impact of Johnson & Johnson’s Health & Wellness Program on employee health risks. Journal of Occupational & Environmental Medicine 2002;44:417-24.

Goetzel RZ, Sepulveda M, Knight K, Eisen M, Wade S, et al. Association of IBM’s “A Plan for Life” health promotion program with changes in employees’ health risk status. Journal of Occupational Medicine 1994;36:1005-9.

Gomel M, Oldenburg B, Simpson JM. Work-site cardiovascular risk reduction: a randomized trial of health risk assessment, education, counseling, and incentives. American Journal of Public Health 1993;83:1231-8.

Gomel MK, Oldenburg B, Simpson JM, Chilvers M, Owen N. Composite cardiovascular risk outcomes of a work-site intervention trial. American Journal of Public Health 1997;87:673-6.

Gregg W, Foote A, Erfurt JC, Heirich MA. Worksite follow-up and engagement strategies for initiating health risk behavior changes. Health Education Quarterly 1990;17:455-78.

Guico-Pabia CJ, Cioffi L, Shoner LG. The Lucent-Takes-Heart cardiovascular health management program. Successful workplace screening. AAOHN Journal 2002;50: 365-72.

Hartman TJ, Himes JH, McCarthy PR, Kushi LH. Effects of a low-fat, worksite intervention on blood lipids and lipoproteins. Journal of Occupational & Environmental Medicine 1995;37:690-6.

Hartman TJ, McCarthy PR, Himes JH. Use of eating-pattern messages to evaluate changes in eating behaviors in a worksite cholesterol education program. Journal of the American Dietary Association 1993;93:1119-23.

Heirich MA, Foote A, Erfurt JC, Konopka B. Work-site physical fitness programs. Comparing the impact of different program designs on cardiovascular risks. Journal of Occupational Medicine 1993;35:510-7.

Holt MC, McCauley M, Paul D. Health impacts of AT&T’s Total Life Concept (TLC) program after five years. American Journal of Health Promotion 1995;9:421-5.

Knight KK, Goetzel RZ, Fielding JE, Eisen M, Jackson GW, et al. An evaluation of Duke University’s LIVE FOR LIFE health promotion program on changes in worker absenteeism.Journal of Occupational Medicine 1994;36:533-6.

Kronenfeld JJ, Jackson K, Blair SN, Davis K, Gimarc JD, et al. Evaluating health promotion: a longitudinal quasi-experimental design. Health Education Quarterly 1987;14:123-39.

Maes S, Verhoeven C, Kittel F, Scholten H. Effects of a Dutch work-site wellness-health program: the Brabantia Project. American Journal of Public Health 1998;88: 1037-41.

McCarthy PR, Lansing D, Hartman TJ, Himes JH. What works best for worksite cholesterol education? Answers from targeted focus groups. Journal of the American Dietary Association1992;92:978-81.

Merrill BE, Sleet DA. Safety belt use and related health variables in a worksite health promotion program. Health Education Quarterly 1984;11:171-9.

Musich S, McDonald T, Hirschland D, Edington D. Examination of risk status transitions among active employees in a comprehensive worksite health promotion program. Journal of Occupational & Environmental Medicine 2003;45:393-9.

Nilsson PM, Klasson EB, Nyberg P. Life-style intervention at the worksite – reduction of cardiovascular risk factors in a randomized study. Scandinavian Journal of Work, Environment & Health 2001;27:57-62.

Oldenburg B, Owen N, Parle M, Gomel M. An economic evaluation of four work site based cardiovascular risk factor interventions. Health Education Quarterly 1995;22: 9-19.

Ostwald SK. Changing employees’ dietary and exercise practices: an experimental study in a small company. American Journal of Health Promotion 1989;4:141-2.

Ozminkowski RJ. Long-term impact of Johnson & Johnson’s Health & Wellness Program on health care utilization and expenditures. Journal of Occupational & Environmental Medicine2002;44:21-9.

Ozminkowski RJ, Goetzel RZ, Smith MW, Cantor RI, Shaughnessy A, Harrison M. The Impact of the Citibank, NA, Health Management Program on Changes in Employee Health Risks Over Time. Journal of Occupational & Environmental Medicine 2000;42: 502-11.

Ozminkowski RJ, Dunn RL, Goetzel RZ, Cantor RI, Murnane J, Harrison M. Return on investment evaluation of the Citibank, NA, Health Management Program. American Journal of Health Promotion 1999;14:31-43.

Pelletier B, Boles M, Lynch W. Change in health risks and work productivity over time. Journal of Occupational & Environmental Medicine 2004;46.

Pilon BA, Renfroe D. Evaluation of an employee health risk appraisal program. AAOHN Journal1990;38:230-5.

Pilon BA, Renfroe D. Evaluation of an employee health risk appraisal program. American Association of Occupational Health Nurses Journal 1990;38:230-5.

Poole K, Kumpfer K, Pett M. The impact of an incentive-based worksite health promotion program on modifiable health risk factors. American Journal of Health Promotion 2001;16:21-6, ii.

Purath J, Miller AM, McCabe G, Wilbur J. A brief intervention to increase physical activity in sedentary working women. Canadian Journal of Nursing Research 2004;36:76-91.

Puska P, Niemensivu H, Puhakka P, Alhainen L, Koskela K, et al. Results of a one-year worksite and mass media based intervention on health behaviour and chronic disease risk factors. Scandinavian Journal of Work, Environment & Health 1988;16: 241-50.

Schultz AB, Lu C, Barnett TE, Yen LT, McDonald T, et al. Influence of participation in a worksite health-promotion program on disability days. Journal of Occupational & Environmental Medicine 2002;44:776-80.

Sepulveda M, Goetz A, Grana J. Measuring second-order selection bias in a work site health program. Journal of Occupational & Environmental Medicine 1994;36:326-33.

Serxner S, Gold D, Anderson D, Williams D. The impact of a worksite health promotion program on short-term disability usage. Journal of Occupational & Environmental Medicine2001;43:25-9.

Serxner SA, Gold DB, Bultman KK. The impact of behavioral health risks on worker absenteeism. Journal of Occupational & Environmental Medicine 2001;43:347-54.

Shi L. Impact of increasing intensity of health promotion intervention on risk reduction.Evaluation & the Health Professions 1992;15:3-25.

Shi L. Health promotion, medical care use, and costs in a sample of worksite employees.Evaluation Review 1993;17:475-87.

Shimizu T, Nagashima S, Mizoue T, Higashi T, Nagata S. A psychosocial-approached health promotion program at a Japanese worksite. Journal of the University of Occupational & Environmental Health 2003;25:23-34.

Shipley RH, Orleans T, Wilbur CS, Piserchia PV, McFadden DW. Effect of the Johnson & Johnson Live for Life Program on Employee Smoking. Preventive Medicine 1988; 12:25-34.

Sloan RP, Gruman J. Participation in workplace health promotion programs: the contribution of health and organizational factors. Health Education Quarterly 1988;15:269-88.

Sorensen G, Stoddard A, Hunt MK, Hebert JR, Ockene JK, et al. The effects of a health promotion-health protection intervention on behavior change: the WellWorks Study.American Journal of Public Health 1998;88:1685-90.

Sorensen G, Stoddard AM, LaMontagne AD, Emmons K, Hunt MK, et al. A comprehensive worksite cancer prevention intervention: behavior change results from a randomized controlled trial (United States). Cancer Causes Control 2002;13: 493-502.

Sorensen G, Thompson B, Glanz K, Feng Z, Kinne S, et al. Work site-based cancer prevention: primary results from the Working Well Trial. American Journal of Public Health1996;86:939-47.

Sorensen G, Himmelstein JS, Hunt MK, Youngstrom R, Hebert JR, et al. A model for worksite cancer prevention: integration of health protection and health promotion in the WellWorks Project. American Journal of Public Health 1995;10:55-62.

Spilman MA, Goetz A, Schultz J, Bellingham R, Johnson D. Effects of a corporate health promotion program. Journal of Occupational Medicine 1986;28:285-9.

Stevens MM, Paine-Andrews A, Francisco VT. Improving employee health and wellness: a pilot study of the employee-driven Perfect Health Program. American Journal of Health Promotion 1996;11:12-14.

Strychar IM, Champagne F, Ghadirian P, Bonin A, Jenicek M, Lasater TM. Impact of receiving blood cholesterol test results on dietary change. American Journal of Preventive Medicine1998;14:103-10.

Tilley BC, Glanz K, Kristal AR, Hirst K, Li S, Vernon SW et al. (1999). Nutrition intervention for high-risk auto workers: Results of the Next Step Trial. Preventive Medicine, 28, 284-292.

Tilley BC, Vernon SW, Glanz K, Myers R, Sanders K, et al. Worksite cancer screening and nutrition intervention for high-risk auto workers: design and baseline findings of the Next Step Trial. Preventive Medicine 1997;26:227-35.

Tilley BC, Vernon SW, Myers R, Glanz K, Lu M, et al. The Next Step Trial: impact of a worksite colorectal cancer screening promotion program. Preventive Medicine 1999; 27:276-83.

Walton C, Timms J. Providing worksite health promotion through university-community partnerships: the South Carolina DOT project. American Association of Occupational Health Nurses Journal 1999;47:449-55.

Weinstein ND, Grubb PD, Vautier JS. Increasing automobile seat belt use: an intervention emphasizing risk susceptibility. Journal of Applied Psychology 1986;71: 285-90.

Williams A, Wold J, Dunkin J, Idleman L, Jackson C. CVD prevention strategies with urban and rural African American women. Applied Nursing Research 2004;17:187-94.

Wood EA. Lifestyle risk factors and absenteeism trends – a six-year corporate study. AWHP’S Worksite Health 1997;4:32-5.

Wood EA, Olmstead GW, Craig JL. An evaluation of lifestyle risk factors and absenteeism after two years in a worksite health promotion program. American Journal of Health Promotion1989;4:128-33.

World Health Organisation European Collaborative Group. European collaborative trial of multifactorial prevention of coronary heart disease: final report on the 6-year results. Lancet1986;1:869-72.

World Health Organization. An international controlled trial in the mulitfactorial prevention of coronary heart disease. International Journal of Epidemiology 1974;3: 219-24.

World Health Organization European Collaborative Group. Multifactorial trial in the prevention of coronary heart disease: 2. Risk factor changes at two and four years.European Heart Journal 1982;3:184-90.

World Health Organization European Collaborative Group. Multifactorial trial in the prevention of coronary heart disease: 3. Incidence and mortality results. European Heart Journal 1983;4:141-7.

Yen L, Edington MP, McDonald T, Hirschland D, Edington DW. Changes in health risks among the participants in the United Auto Workers – General Motors LifeSteps Health Promotion Program. American Journal of Health Promotion 2001;16:7-15.

Economic Review

Aldana SG, Jacobson BH, Harris CJ, Kelley PL. Mobile work site health promotion programs can reduce selected employee health risks. J Occup Med 1993;35(9):922 8.

Bertera RL. The effects of workplace health promotion on absenteeism and employment costs in a large industrial population. Am J Public Health 1990; 80(9):1101 5.

Burton W, Conti D. Disability management: corporate medical department management of employee health and productivity. J Occup Environ Med 2000;42:1006 12.

Erfurt JC, Foote A, Heirich MA. The cost effectiveness of worksite wellness programs for hypertension control, weight loss, and smoking cessation. J Occup Med 1991;33(9):962 70.

Harvey MR, Whitmer RW, Hilyer JC, Brown KC. The impact of a comprehensive medical benef t cost management program for the City of Birmingham: results at f ve years. Am J Health Promot 1993;7(4):296 303.

Leutzinger J, Hawes C, Hunnicutt D, Richling D. Predicting the ratio of benef t to cost in a cardiovascular disease-prevention program. Managing Employee Health Benef ts 1995;Fall:1 10.

Ozminkowski RJ, Dunn RL, Goetzel RZ, Cantor RI, Murnane J, Harrison M. Return on investment evaluation of the Citibank, N.A. Health Management Program. Am J Health Promot 1999;14(1):31 43.

Schultz AB, Lu C, Barnett TE, et al. Influence of participation in a worksite health-promotion program on disability days. J Occup Environ Med 2002;44(8):776 80.

Shi L. Health promotion, medical care use, and costs in a sample of worksite employees. Eval Rev 1993;17(5):475 87.

The following outlines the search strategy used for reviews of assessment of health risks with feedback when used alone, and when combined with health education programs, with or without additional interventions.

The articles to be reviewed were obtained from systematic searches of multiple databases, reviews of bibliographic reference lists, and consultations with experts in the field. The following databases were searched: Medline, Employee Benefits, NTIS, Sports Information Resource Center, Cambridge Scientific Abstracts, Inc., Business Week, ABI Inform, Health Promotion and Education, Cumulative Index to Nursing & Allied Health Literature, Office of Smoking and Health, AIDSLine, PsycInfo, and Sociological Abstracts.

Database: Ovid MEDLINE(R) [1966 to June Week 4 2005]

1. exp health behavior/ or exp health education/ or health promotion/ or exp primary prevention/ (218287)
2. exp work/ or workplace/ or occupational health/ (22008)
3. risk assessment/ or risk factors/ or health status indicators/ or mass screening/ (357682)
4. (health risk assessment$ or health risk appraisal$ or health screening$ or health status assessment$ or health assessment$ or screening$).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (189292)
5. (risk awareness or risk profile$ or lifestyle check$ or health quiz or health measur$ or health report$ or risk identification).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (5429)
6. 3 or 4 or 5 (490335)
7. (health maintenance organization$ or health clinic$ or insurance compan$).mp. [mp=title, original title, abstract, name of substance word, subject heading word] (18831)
8. 2 or 7 (40777)
9. 1 and 6 and 8 (607)
10. limit 9 to english language (559)

Database: Employee Benefits_1986-2005/Jun (c) 2005

Sets selected:

Set Items Description

1. 831 HEALTH()BEHAVIOR OR HEALTH()EDUCATION OR HEALTH()PROMOTION OR PRIMARY()PREVENTION
2. 1291 HEALTH()RISK()ASSESSMENT? OR HEALTH()RISK()APPRAISAL?
   OR HEALTH()SCREENING? OR HEALTH()STATUS()ASSESSMENT?
   OR HEALTH()ASSESSMENT? OR SCREENING?
3. 554 RISK()AWARENESS OR RISK()PROFILE?
   OR LIFESTYLE()CHECK? OR HEALTH()QUIZ
   OR HEALTH()MEASUR? OR HEALTH()REPORT?
   OR RISK()IDENTIFICATION
4. 1360 S2 OR S3
5. 310 S1 AND S4

Databases:BAMP_2005/Jul W2 (c) 2005 and PAIS Int._1976-2005/Jun (c) 2005

Sets selected:

Set Items Description

1. 2363 HEALTH()BEHAVIOR OR HEALTH()PROMOTION OR HEALTH()EDUCATION OR PRIMARY()PREVENTION
2. 7157 HEALTH()RISK()ASSESSMENT? OR HEALTH()RISK()APPRAISAL? OR HEALTH()SCREENING? OR HEALTH()STATUS()ASSESSMENT? OR HEALTH()ASSESSMENT? OR SCREENING?
3. 509 RISK()AWARENESS OR RISK()PROFILE? OR LIFESTYLE()CHECK? OR HEALTH()QUIZ? OR HEALTH()MEASUR? OR HEALTH()REPORT? OR RISK()IDENTIFICATION
4. 7632 S2 OR S3
5. 255 S1 AND S4
6. 174772 WORKSITE? OR WORKPLACE? OR EMPLOYER? OR EMPLOYEE? OR WORKER?
7. 196 S5 AND S6
8. 195 RD S7 (unique items)
9. 195 S8/ENG

Database: TGG Management Contents(R)_86-2005/Jul W2 (c) 2005 and Business Week_1985-2005/Jul 21 (c) 2005

Sets selected:

Set Items Description

1. 561 HEALTH()BEHAVIOR OR HEALTH()PROMOTION OR HEALTH()EDUCATION OR PRIMARY()PREVENTION
2. 2925 HEALTH()RISK()ASSESSMENT? OR HEALTH()RISK()APPRAISAL? OR HEALTH()SCREENING? OR HEALTH()STATUS()ASSESSMENT? OR HEALTH()ASSESSMENT? OR SCREENING?
3. 695 RISK()AWARENESS OR RISK()PROFILE? OR LIFESTYLE()CHECK? OR HEALTH()QUIZ? OR HEALTH()MEASUR? OR HEALTH()REPORT? OR RISK()IDENTIFICATION
4. 3582 S2 OR S3
5. 103 S1 AND S4
6. 82979 WORKSITE? OR WORKPLACE? OR EMPLOYER? OR EMPLOYEE? OR WORKER?
7. 78 S5 AND S6
8. 78 RD S7 (unique items)
9. 77 S7/ENG

Database: ABI Inform(R)_1971-2005/Jul 22 (c)

Sets selected:

Set Items Description

1. 6388 HEALTH()BEHAVIOR OR HEALTH()PROMOTION OR HEALTH()EDUCATION OR PRIMARY()PREVENTION
2. 6342 (HEALTH()RISK()ASSESSMENT? OR HEALTH()RISK()APPRAISAL? OR HEALTH()SCREENING? OR HEALTH()STATUS()ASSESSMENT? OR HEALTH()ASSESSMENT? OR SCREENING?)/TI,AB
3. 1039 (RISK()AWARENESS OR RISK()PROFILE? OR LIFESTYLE()CHECK? OR HEALTH()QUIZ? OR HEALTH()MEASUR? OR HEALTH()REPORT? OR RISK()IDENTIFICATION)/TI,AB
4. 7371 S2 OR S3
5. 252 S1 AND S4
6. 517172 WORKSITE? OR WORKPLACE? OR EMPLOYER? OR EMPLOYEE? OR WORKER?
7. 184 S5 AND S6
8. 184 S9/ENG

Database: CDP File (Health Promotion and Education Database)

Descriptors: “WORKSITE” and “HEALTH RISK APPRAISAL” and
Form: “JOURNAL ARTICLE” OR
Descriptors: “worksite” not “health risk appraisal” and
Textwords: HEALTH ADJ1 RISK ADJ1 ASSESSMENT* OR HEALTH ADJ1 SCREEN* OR RISK ADJ1 ASSESSMENT* OR HEALTH ADJ1 ASSESSMENT* OR *RISK ADJ1 (AWARENESS* OR PROFILE* OR IDENTIFICATION) OR HEALTH ADJ1 (MEASURING OR REPORT* OR QUIZ*) OR LIFESTYLE ADJ1 CHECK* and Form: “JOURNAL ARTICLE”
TOTAL = 212

Database: CINHAL

Descriptors: “WORKSITE” and “HEALTH RISK APPRAISAL” and
Form: “JOURNAL ARTICLE” OR
Descriptors: “worksite” not “health risk appraisal” and
Textwords: HEALTH ADJ1 RISK ADJ1 ASSESSMENT* OR HEALTH ADJ1 SCREEN* OR RISK ADJ1 ASSESSMENT* OR HEALTH ADJ1 ASSESSMENT* OR *RISK ADJ1 (AWARENESS* OR PROFILE* OR IDENTIFICATION) OR HEALTH ADJ1 (MEASURING OR REPORT* OR QUIZ*) OR LIFESTYLE ADJ1 CHECK* and Form: “JOURNAL ARTICLE”
TOTAL = 212

Database: NTIS, Intl Cpyrght All Rights Res

Sets selected:

Set Items Description

1. 9285 HEALTH()BEHAVIOR OR HEALTH()EDUCATION OR HEALTH()PROMOTION OR PRIMARY()PREVENTION
2. 4804 WORKSITE OR WORKPLACE OR WORK-SITE OR OCCUPATIONAL()HEALTH
3. 289 S1 AND S2
4. 17896 HEALTH()RISK()ASSESSMENT? OR HEALTH()RISK()APPRAISAL? OR HEALTH()SCREENING? OR HEALTH()STATUS()ASSESSMENT? OR HEALTH()ASSESSMENT? OR SCREENING?
5. 477 RISK()AWARENESS OR RISK()PROFILE? OR LIFESTYLE()CHECK? OR HEALTH()QUIZ OR HEALTH()MEASUR? OR HEALTH()REPORT? OR RISK()IDENTIFICATION
6. 18332 S4 OR S5
7. 47 S3 AND S6

Database: SportDiscuss

Sets selected:

Set Items Description

1. 9166 HEALTH()BEHAVIOR OR HEALTH()EDUCATION OR HEALTH()PROMOTION OR PRIMARY()PREVENTION
2. 1589 WORKSITE OR WORKPLACE OR WORK-SITE OR OCCUPATIONAL()HEALTH
3. 479 S1 AND S2
4. 2169 HEALTH()RISK()ASSESSMENT? OR HEALTH()RISK()APPRAISAL? OR HEALTH()SCREENING? OR HEALTH()STATUS()ASSESSMENT? OR HEALTH()ASSESSMENT? OR SCREENING?
5. 176 RISK()AWARENESS OR RISK()PROFILE? OR LIFESTYLE()CHECK? OR HEALTH()QUIZ OR HEALTH()MEASUR? OR HEALTH()REPORT? OR RISK()IDENTIFICATION
6. 2341 S4 OR S5
7. 22 S3 AND S6
8. 22 S7/ENG

Database: OSH (Office of Smoking and Health)

Descriptors: (“WORKERS” OR “WORKPLACE*” OR “WORKSITE CESSATION PROGRAMS”) AND (“HEALTH EDUCATION*” OR “HEALTH PROMOTION*” OR
“PREVENTION*” OR “INTERVENTION*”) and
Textwords: RISK* OR SCREEN* OR ASSESSMENT* OR LIFESTYLE ADJ1 CHECK OR HEALTH ADJ1 QUIZ* OR HEALTH ADJ1 MEASUR* OR HEALTH ADJ1 REPORT*
Total 20

Database: Sociological Abstracts [1963 to April 2005]

1. exp health behavior/ or exp health education/ or exp prevention/ or health promotion.mp. (8199)
2. (workplace or worksite or work-site or occupational).mp. (20332)
3. (health risk assessment$ or health risk appraisal$ or health screening$ or health status assessment$ or health assessment$ or screening$).mp. (1675)
4. (risk awareness or risk profile$ or lifestyle check$ or health quiz or health measur$ or health report$ or risk identification).mp. (376)
5. 1 and 2 (242)
6. 3 or 4 (2027)
7. 5 and 6 (19)
8. limit 7 to english language (19)
9. from 8 keep 1-19 (19)

Database: PsycINFO [1967 to June Week 4 2005]

1. exp health behavior/ or exp health education/ or health promotion/ or exp prevention/ (36831)
2. (workplace or worksite or work-site or occupational).mp. [mp=title, abstract, subject headings, table of contents, key concepts] (27805)
3. 1 and 2 (1130)
4. (health risk assessment$ or health risk appraisal$ or health screening$ or health status assessment$ or health assessment$ or screening$).mp. [mp=title, abstract, subject headings, table of contents, key concepts] (19187)
5. (risk awareness or risk profile$ or lifestyle check$ or health quiz or health measur$ or health report$ or risk identification).mp. (1259)
6. 4 or 5 (20366)
7. 3 and 6 (101)
8. limit 7 to english language (99)
9. from 8 keep 1-99 (99)

Database: AIDSLINE [1980 to December 2000] CLOSED FILE

1. exp health behavior/ or exp health education/ or health promotion/ or exp primary prevention/ (14069)
2. exp work/ or workplace/ or occupational health/ (347)
3. risk assessment/ or risk factors/ or health status indicators/ or mass screening/ (18933)
4. (health risk assessment$ or health risk appraisal$ or health screening$ or health status assessment$ or health assessment$ or screening$).mp. [mp=title, abstract, mesh subject heading] (6055)
5. (risk awareness or risk profile$ or lifestyle check$ or health quiz or health measur$ or health report$ or risk identification).mp. [mp=title, abstract, mesh subject heading] (239)
6. 3 or 4 or 5 (23204)
7. (health maintenance organization$ or health clinic$ or insurance compan$).mp. [mp=title, abstract, mesh subject heading] (488)
8. 2 or 7 (831)
9. 1 and 6 and 8 (36)
10. limit 9 to english language (36)
11. limit 10 to nonmedline (23)
12. from 11 keep 1-23 (23)

The following considerations are drawn from studies included in the evidence review, the broader literature, and expert opinion.

• Employers may be reluctant to implement interventions involving AHRF due to employee concerns over breach of conf dentiality of health records to other employees or to health insurance providers. Programs that offer incentives for completion of HRA tools or require that employees meet specif c health standards (for example, they must fall within a particular BMI range) may exacerbate concerns.
• Engaging employees can be challenging. Those who think or know that they have important health risks may be least likely to participate.
• Even if there is broad participation in AHRF, there may be low participation in intervention components offered in addition to AHRF. In such cases, employers may be inclined to reduce the scope of or cancel these components.
• While not evaluated in the included studies, interventions may lead to increased employee satisfaction.
• The review team noted potential harms, including increased anxiety for workers during the feedback portion; false positives; and overestimates of risk status.

Healthy People 2030

Healthy People 2030 includes the following objectives related to this CPSTF recommendation.

• Increase the proportion of worksites that offer an employee health promotion program — ECBP‑D03
• Increase the proportion of worksites that offer an employee physical activity program — ECBP‑D04
• Increase the proportion of worksites that offer an employee nutrition program — ECBP‑D05