A Systematic Review of Selected Interventions for ?· A Systematic Review of Selected Interventions for Worksite Health Promotion The Assessment of Health Risks with Feedback Robin

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<ul><li><p>FaHCtN(fEt</p><p>P</p><p>A Systematic Review of SelectedInterventions for Worksite</p><p>Health PromotionThe Assessment of Health Risks with Feedback</p><p>Robin E. Soler, PhD, Kimberly D. Leeks, PhD, MPH, Sima Razi, MPH,David P. Hopkins, MD, MPH, Matt Griffith, MPH, Adam Aten, MPH,</p><p>Sajal K. Chattopadhyay, PhD, Susan C. Smith, MPA, MLIS, Nancy Habarta, MPH,Ron Z. Goetzel, PhD, Nicolaas P. Pronk, PhD, Dennis E. Richling, MD,</p><p>Deborah R. Bauer, MPH, RN, CHES, Leigh Ramsey Buchanan, PhD, MPH,Curtis S. Florence, PhD, Lisa Koonin, MN, MPH, Debbie MacLean, BS, ATC/L,</p><p>Abby Rosenthal, MPH, Dyann Matson Koffman, DrPH, MPH,James V. Grizzell, MBA, MA, CHES, Andrew M. Walker, MPH, CHES, the Task Force on</p><p>Community Preventive Services</p><p>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.</p><p>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.</p><p>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.</p><p>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</p><p>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-</p><p>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</p><p>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.</p><p>0749-3797/00/$17.00doi: 10.1016/j.amepre.2009.10.030</p>on DC; HealthPartners Research Foundation (Pronk), Bloomington,<p>ublished by Elsevier Inc. on behalf of American Journal of Preventive Medicine Am J Prev Med 2010;38(2S)S237S262 S237</p><p>mailto:RSoler@cdc.gov</p></li><li><p>I</p><p>Oh9oecthfrahwstfapampfm</p><p>pomhvrpiqpt</p><p>hhoh2vnstsphm</p><p>ocwm</p><p>wRcwtaeDctiwb</p><p>ccU(Cne6EpCCPhstmtHcaiwhir</p><p>G</p><p>Tond</p><p>S238 Soler et al / Am J Prev Med 2010;38(2S):S237S262</p><p>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</p><p>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</p><p>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-</p><p>ent of future risk of death and other adverse health (</p><p>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</p><p>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</p><p>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</p><p>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</p><p>uide to Community Preventive Services</p><p>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</p><p>Community Guide) with the support of the USDHHS in</p><p>www.ajpm-online.net</p></li><li><p>cpomHot</p><p>H</p><p>TaPihbicssosehtwtss8s</p><p>EC</p><p>Urami</p><p>dpisstasslrrl</p><p>eoeodsr</p><p>ptEitm(t</p><p>A</p><p>FHca(iasiiablmadphtrh</p><p>hotttodBAaB</p><p>A</p><p>Soler et al / Am J Prev Med 2010;38(2S):S237S262 S239</p><p>F</p><p>ollaboration with public and private partners. The CDCrovides staff support to the Task Force for developmentf the Community Guide. The book, The Guide to Com-unity Preventive Services: What Works to Promoteealth?17 (also available at www.thecommunityguide.rg/library/default.htm) presents the background andhe methods used in developing the Community Guide.</p><p>ealthy People 2010 Goals and Objectives</p><p>here are well over 400Healthy People 201018 objectives,ndmost are relevant to the working population.Healthyeople 2010 includes among its top ten leading healthndicators six variables addressed in most assessments ofealth risk: physical activity, overweight and obesity, to-acco use, substance use (typically limited to alcohol use),njury and violence (most often seatbelt use), and health-are service use (which would include a range of cancercreening services).19 The interventions reviewed herehould be useful in reaching several Healthy People 2010bjectives in these categories, which identify some of theignifcant preventable threats to health and focus thefforts of public health systems, legislators, policymakers,ealthcare organizations, and employers for addressinghose threats. Healthy People 2010 also includes twoorksite-specifc objectives. Objectives 7-5 and 7-6 statehat (1) at least three quarters of U.S. employers, in work-ites with 50 or more employees, will offer a comprehen-ive employee health promotion program; and (2) at least8% of U.S. employees will be participating in employer-ponsored health promotion activities.</p><p>vidence Acquisitiononceptual Approach</p><p>sing methods developed for the Community Guide,17 theeview team conducted a set of systematic reviews to evalu-te the evidence on effectiveness of AHRF when imple-ented alone and when used in combination with other</p><p>ntervention components (AHRF Plus) in worksite settings.In brief, this process involved forming a systematic reviewevelopment team composed of experts in worksite healthromotion, public health, and systematic reviews; develop-ng a conceptual approach to organizing, grouping, andelecting interventions; selecting interventions to evaluate;earching for and retrieving available research evidence onhe effects of those interventions; assessing the quality of andbstracting information from each study that meets inclu-ion criteria; assessing the quality of and drawing conclu-ions about the body of evidence of effectiveness; and trans-ating the evidence on intervention effectiveness intoecommendations. Evidence was collected and summarizedegarding the effectiveness of interventions for altering se-</p><p>ected health-related outcomes and on positive or negative d</p><p>ebruary 2010</p><p>ffects of the intervention on other health and nonhealthutcomes. When an intervention has been shown to beffective, information is also included about the applicabilityf evidence (i.e., the extent to which available effectivenessata might generalize to diverse population segments andettings), the economic impact of the intervention, and bar-iers to implementation.To be included in the reviews, a study had to: (1) berimary research published in a peer-reviewed journal,echnical report, or government report; (2) be published innglish between January 1980 and June 2005; (3) meet min-mum research quality criteria for study design and execu-ion;20 (4) evaluate the effects of an AHRF when imple-ented in a population of workers in worksite settings; and5) evaluate change in one ormore outcomes of interest (seehe Outcomes Evaluated section).</p><p>ssessment of Health Risks with Feedback</p><p>or this review the team used the term Assessment ofealth Risks with Feedback to refer to a process that in-ludes three elements: (1) the collection of informationbout at least two personal health behaviors or indicators;2) translation of the information collected into one ormorendividual risk scores or categoric descriptions of risk status;nd (3) feedback to the participants regarding their risktatus, either overall or with respect to specifc risk behav-ors. Although AHRF can be offered as an independentntervention, it is often applied as a gateway intervention tobroader worksite health promotion program, which maye risk-specifc or broad in scope, and which may be ofimited duration and intensity or may occur over manyonths or years (with few ormultiple contacts).When useds a gateway intervention, the assessment is typically con-ucted one or more times, and the feedback is offered to thearticipant along with information about the identifedealth risks, information about programs directed towardhe prevention or treatment of the identifed health risks, oreferrals to programs or providers addressing the identifedealth risks.The frst element of AHRF, the collection of individualealth information, is typically done by questionnaire, butccasionally data are gathered from medical records orhrough personal health interviews. Both the form and func-ion of this data collection have changed in concert withechnologic changes. Some of these changes include the usef computers for generation of health-risk scores, web-basedata collection, and generation of individualized reports.iometric screenings, an optional element of the basicHRF intervention, are often used to obtain up-to-date andccurate measures of blood pressure, cholesterol, weig...</p></li></ul>


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