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    A Systematic Review of SelectedInterventions for Worksite

    Health PromotionThe Assessment of Health Risks with Feedback

    Robin E. Soler, PhD, Kimberly D. Leeks, PhD, MPH, Sima Razi, MPH,David P. Hopkins, MD, MPH, Matt Griffith, MPH, Adam Aten, MPH,

    Sajal K. Chattopadhyay, PhD, Susan C. Smith, MPA, MLIS, Nancy Habarta, MPH,Ron Z. Goetzel, PhD, Nicolaas P. Pronk, PhD, Dennis E. Richling, MD,

    Deborah R. Bauer, MPH, RN, CHES, Leigh Ramsey Buchanan, PhD, MPH,Curtis S. Florence, PhD, Lisa Koonin, MN, MPH, Debbie MacLean, BS, ATC/L,

    Abby Rosenthal, MPH, Dyann Matson Koffman, DrPH, MPH,James V. Grizzell, MBA, MA, CHES, Andrew M. Walker, MPH, CHES, the Task Force on

    Community Preventive Services

    Background: Many health behaviors and physiologic indicators can be used to estimate ones likeli-hood of illness or premature death.Methods have been developed to assess this risk,most notably the useof a health-risk assessment or biometric screening tool. This report provides recommendations on theeffectiveness of interventions that use an Assessment of Health Risks with Feedback (AHRF) when usedalone or as part of a broader worksite health promotion program to improve the health of employees.

    Evidence acquisition: The Guide to Community Preventive Services methods for systematic re-views were used to evaluate the effectiveness of AHRF when used alone and when used in combina-tionwith other intervention components. Effectiveness was assessed on the basis of changes in healthbehaviors and physiologic estimates, but was also informed by changes in risk estimates, healthcareservice use, and worker productivity.

    Evidence synthesis: ThereviewteamidentifedstrongevidenceofeffectivenessofAHRFwhenusedwithhealtheducationwithorwithoutother interventioncomponents forfveoutcomes.Thereissuffcientevidenceof effectiveness for four additional outcomes assessed.There is insuffcient evidence todetermine effectivenessforotherssuchaschanges inbodycompositionandfruitandvegetable intake.Theteamalso foundinsuffcientevidence to determine the effectiveness ofAHRFwhen implemented alone.

    Conclusions: The results of these reviews indicate that AHRF is useful as a gateway intervention toa broader worksite health promotion program that includes health education lasting 1 hour orrepeating multiple times during 1 year, and that may include an array of health promotion activities.These reviews form the basis of the recommendations by the Task Force on Community PreventiveServices presented elsewhere in this supplement.(Am J PrevMed 2010;38(2S):S237S262) Published by Elsevier Inc. on behalf of American Journal of PreventiveMedicine

    rom the Community Guide Branch, Division of Health Communicationnd Marketing, National Center for Health Marketing (Soler, Leeks, Razi,opkins, Griffth, Aten, Chattopadhyay, Habarta); Offce of the Director,oordinating Center for Infectious Diseases (Koonin); Information Cen-er (Smith), and Division of Nutrition, Physical Activity, and Obesity,ational Center for Chronic Disease Prevention and Health PromotionBuchanan,MatsonKoffman, Rosenthal), CDC,Atlanta,Georgia; Instituteor Health and Productivity Studies, Rollins School of Public Health,mory University and Thomson Reuters Healthcare (Goetzel) Washing-

    Minnesota; CorSolutions (Richling), Chicago, Illinois;McKingConsulting(Bauer), Olympia,Washington; School of PublicHealth, EmoryUniversity(Florence), Atlanta, Georgia; Coca Cola Company (MacLean), Atlanta,Georgia; Cal Poly Pomona and George Washington University (Grizell),Pomona, California; and Private consultant (Walker), Decatur, Georgia

    Address correspondence and reprint requests to: Robin E. Soler, PhD,CommunityGuide Branch, Centers forDiseaseControl andPrevention, 1600Clifton Road, MS E-69, Atlanta GA 30333. E-mail: RSoler@cdc.gov.

    0749-3797/00/$17.00doi: 10.1016/j.amepre.2009.10.030

    on DC; HealthPartners Research Foundation (Pronk), Bloomington,

    ublished by Elsevier Inc. on behalf of American Journal of Preventive Medicine Am J Prev Med 2010;38(2S)S237S262 S237


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    S238 Soler et al / Am J Prev Med 2010;38(2S):S237S262

    ntroductionver the past 25 years, the number of organiza-tions and companies that offer a health promo-tion program for their employees at the worksite

    as increased, with 81% of worksites in 1990 and nearly0% of all workplaces with at least 50 employees by 2000,ffering some type of health promotion program for theirmployees.1,2 This is due, in part, to the fact that Ameri-an adults are spending increasingly larger portions ofheir waking hours at work, and because poor employeeealth comes at a cost to employers. Furthermore, the topve health conditions (diseases of the heart, cancers, ce-ebrovascular disease, chronic lower respiratory disease,nd unintentional injuries) are potentially responsive toealth intervention. Several of the diseases associatedith these conditions and almost 55% of all deaths aretrongly affected by four modifable behavioral factors3

    hat may be addressed in the worksite setting. These fouractorstobacco use, poor diet, physical inactivity, andlcohol useare related to fve of the 20 most costlyhysical health conditions for U.S. employers (includingngina pectoris [chest pain], diabetes mellitus, acuteyocardial infarction [heart attack], chronic obstructiveulmonary disease, and back pain).4 These factors giveurther reason for the widespread offering of health pro-otion programs at worksites.One of the components of aworksite health promotionrogrammost often offered is the health-risk assessmentr biometric screening, with close to 50%of companies ofore than 750 employees reporting having offered aealth-risk assessment, according to a 2004 national sur-ey of worksite health promotion.5 Assessments of healthisks may be of interest to worksite health promotionlanners because they are easy to administer (computer-zed versions are available), convey a lot of informationuickly, allow for access to a large number of people,rovide workforce-wide estimates, and allow the poten-ial for follow-up.Historically, the terms health-risk appraisal andealth-risk assessment, which share the acronym HRA,ave been used interchangeably to describe assessmentsf health risks. Although the assessment of health risksas been conducted in community settings formore thandecades, no consensus defnition exists. HRA has beenariously described as a tool or questionnaire, as a tech-ique, andmore recently, as a process with three or moreteps.68 Most authors in the feld agree, though, thathere are basic elements of HRAs: the assessment of per-onal health habits and risk factors (which may be sup-lemented by biomedical measurements of physiologicealth); a quantitative estimation or qualitative assess-

    ent of future risk of death and other adverse health (

    utcomes; and provision of feedback in the form of edu-ational messages and counseling that describe ways inhich changing one or more behavioral risk factorsight alter the risk of disease or death.68

    This report provides evidence on the effectiveness oforksite interventions that use an Assessment of Healthisks with Feedback (AHRF) as the primary interventionomponent (when used alone) or as part of a broaderorksite health promotion program (when health educa-ion and other health promotion components are offereds follow-up to the assessment) to improve the health ofmployees. It addresses three main research questions:oes AHRF, when used alone, lead to behavior change orhange in health outcomes among employees? Does thisype of assessment, when used with other worksite-basedntervention components result in change? And fnally,hat types of behaviors or health outcomes are affectedy these interventions?Some of the earliest research in the use of HRAs for

    hanging targeted health behaviors and conditions wasonducted on a large scale at the community level in the.S. with the Multiple Risk Factor Intervention TrialMRFIT).911 This was soon followed by the Europeanollaborative Trial of Multifactoral Prevention of Coro-ary Heart Disease.1215 Conducted in the late 1970s andarly 1980s, this latter initiative focused on more than0,000 working men across worksites in six countries inurope. In the mid-1980s the CDC released an HRA forublic use.8 A partnership between the CDC and thearter Center developed around this tool, and the Carterenter later adopted it (it is now known as the Healthiereople HRA). During this time, use of assessments ofealth risks in the workplace increased dramatically andtudies were conducted to examine different aspects ofhe tools and process of assessments of health risks. In theid-1990s a number of reviews were published on this

    opic, each offering the general conclusion that use ofRAs and other AHRFs, when used alone (not in theontext of broader health education programs), had values tools for assessing the health of populations and forncreasing awareness of potential health risks. Problemsith the quantity and quality of the available evidence,owever, made it diffcult to draw a conclusion about thempact of these interventions on health behaviors andisk factors.7,16

    uide to Community Preventive Services

    he systematic reviews in this report present the fndingsf the independent, nonfederal Task Force on Commu-ity Preventive Services (Task Force). The Task Force iseveloping the Guide to Community Preventive Services

    Community Guide) with the support of the USDHHS in


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