A Health Risk Appraisal (HRA) is sometimes used in conjunction with a health assessment. An HRA is a computerized assessment tool which looks at an individual’s family history, health status, and lifestyle. An HRA seeks to identify precursors associated with premature death or serious illness and quantifies the probable impact for each individual.

An HRA instrument is derived from an understanding of the course of a disease. Based on this understanding, useful prediction instruments can be constructed to assess the health risks of an individual. Individuals with a higher number of health risks tend to have more genuine health problems over time.

Drawing attention to their health risks can help clients reduce risk factors which lead to the onset of unnecessary disease and subsequent premature death. The questionnaire covers lifestyle habits (such as smoking, Seat Belt use, and exercise) and physical measures (such as blood lipids, Blood Pressure levels, height, and weight).

For accuracy, it is crucial to obtain direct measures of Blood Pressure (BP), blood lipids and HDL-cholesterol. The HRA also supports recommendations and indicates what risks are modifiable. Types of measures to assess health risks are discussed under Screening Programs.

The impact of a health risk appraisal is much greater when it is given in-person, with immediate feedback to the client. This also provides an opportunity to invite the client’s participation in continuing health counseling and to gain their written consent to do pro-active outreach to them.

A health age can be computed based on the individual answers to the questionnaire and physiologic factors. The health age may indicate the individual to be younger or older than their chronological age.

HRA programs are one the most prolific types of wellness activities utilized by businesses. Continuing research on HRAs is examining the efficacy of this tool. One of the big advantages of this tool is that it can offer an aggregate group report of a corporation and can be utilized as an assessment tool.

Detailed information is available from the Society of Prospective Medicine (www.spm.org/desc.html) who publishes a handbook on HRAs.

The most common screening performed in Workplace Wellness Programs is heart health assessment.

The screening can include a written heart health test, Blood Pressure (BP) measurement, cholesterol/HDL-cholesterol test, glucose (blood sugar), weight, educational materials specific to diet, nutrition, exercise, blood lipids, smoking, and weight.

The health professional delivering the screening then supports a consultation and helps set goals and objectives with the participant.

The backbone of wellness programming at the workplace is health assessment. It is the first major activity a employer must do when first starting a wellness program. Health assessment is frequently used in conjunction with the administration of a Health Risk Appraisal (HRA).

The most effective way to screen is to utilize a health professional trained in wellness screening techniques and counseling to privately and individually evaluate participants. This wellness professional takes a brief health history and measures Blood Pressure (BP) and cholesterol. With computerized cholesterol desktop analyzers, results are obtained in about four minutes.

Immediate feedback, consultation, and educational materials are provided. For those identified at-risk, follow-up appointments can be scheduled at this time. The whole process takes about twenty minutes per individual. The screening also provides an immediate opportunity to register participants in various health improvement programs based on their interests and identified health risks.

Health screening can be done on an yearly basis and used as a means of monitoring health risks within the worksite.

A health assessment program needs to offer multiple opportunities for participation. The service ought to be offered for all the various shifts of a company. The assessment program ought to be conducted in highly visible areas so the process can be inspected.

Reluctant workers often like to be able to see what the program is about before they take part. When wellness screeners are not busy, they should perform outreach going to areas where workers gather and attempt to recruit workers.

When well-planned and promoted, health assessment can attract participation rates of 60% to 100%. These high participation rates have a beneficial effect on management producing reinforcement for further programming.

Goals are broad-based statements about what the program is expected to do. The intention of the wellness program is to enhance the health of the individual and the company. Goals like mission statements offer direction in a program.

Objectives are specific and provide a means of measurement of the program to determine performance. There are two types of objectives, process and outcome. Process objectives state the activities that need to occur to achieve a desired outcome.

Examples of process objectives are:
• Number of participants screened
• Number of participants in and completing health improvement programs
• Satisfaction of program participants
• Number of participants who were medically referred and saw their physician
• Number of promotional activities
• Number of participants seen in follow-up

Example of outcome objectives are:
• Number of participants who improved fitness level
• Number of participants who lowered cholesterol level
• Number of participants who lost weight, body fat
• Number of participants who quit smoking
• Number of participants with elevated Blood Pressure who lowered their Blood Pressure
• Number of participants whose initial level of alcohol consumption put them at-risk who are no longer at-risk
• Number of participants with risk factors who saw their physician and are being treated for high Blood Pressure or blood lipids years later

Wellness committees are significant in that they create a sense of ownership in the program, and facilitate various tasks involved in wellness programming at the workplace. The Workplace Wellness Program Committee should be composed of a cross-section of workers representing various occupations, levels, and subgroups with the organization.

A common mistake is filling the Company Wellness Program Committee with the most health/fitness-conscious people in the corporation. Don’t rely solely on volunteers to fill a Company Wellness Program Committee. Make sure that your Company Wellness Program Committee members have enough authority in the corporation to run an effective wellness program.

The Workplace Health Promotion Program Committee is made up of workers from the worksite. It oversees the wellness program and helps carry it out. The Workplace Health Promotion Program Committee ought to meet about once a month to review the previous month’s activities and plan future ones. When the program is just starting, the Workplace Health Promotion Program Committee may meet on a weekly basis until things get going.

Committee participants do not carry out healthcare procedures, counsel clients, or handle confidential health information. Wellness professionals perform these tasks.

In general, the Employee Health Promotion Program Committee’s duties fall into three areas: planning, promoting, and helping to run programs.

Starting the programs can include:

• Finding space for activities
• Creating and organizing workplace-wide events such as contests
• Reviewing reports prepared by the program employee and making recommendations

Promoting the program can include:
• Recruiting employees to take part in evaluation and health improvement programs
• Encouraging workers to take part in follow-up counseling
• Organizing promotional strategies using newsletters, signs, bulletin boards, computers, and other media available within the worksite

Helping to run the program can include:
• Setting up equipment for various activities
• Helping to conduct workplace-wide activities
• Monitoring all activities and reviewing the success of the professional employee
• Acting as wellness mentors to fellow employees

The size of the Company Wellness Program Committee will be dependent on the size of the corporation. Pick participants by asking day management to nominate or appoint staff members.

Make an announcement through brochures, memos, and gatherings to recruit potential members. Explain the purpose of the Company Wellness Program Committee, duties and responsibilities, and the time responsibility.

Recognize your Workplace Wellness Program Committee volunteers. Allow them to participate in programs at a reduced cost. Hold appreciation breakfasts/lunches/dinners. Print names of Workplace Wellness Program Committee members on corporation communications about the wellness program.

Purchase special T-shirts, caps, and buttons for them. Write letters to supervisors saying that you appreciate the member’s service. Design awards certificates for members.

The following can be used as a guide for Company Wellness Program Committee size:

• Less than 300 employees   2 to 4
• 300 to 1,000 staff members   4 to 6
• 1,000 staff members or more   6 to 12

Effective wellness programs recognize the effect of building a supportive cultural environment. The worksite culture includes shared values/heartfelt beliefs about what is valuable. It includes social standards of expected and accepted behavior called “cultural norms.”

It includes peer support from family, friends, and co-workers. This support can help one adopt healthy lifestyles. Tools are available to audit a organization.

The long-term success of any wellness program is dependent on the corporate culture.

Some healthy culture signs in a business are:

• employees communicate openly
• Leaders support diversity and opinion
• employees have fun
• Policies support wellness
• employees are encouraged to grow
• staff members work together as a group
• workers’ skills and talents are matched to their jobs.
• Flexible work schedules are available
• Employers consider workers as their most significant asset

Effective wellness programs attempt to establish healthy worksite climates. A healthy worksite climate is one which encourages teamwork, cooperation, and empowerment of the individual.

People have a sense of community, a shared vision, and a positive outlook. Policies encourage and support wellness efforts within the worksite.

• Effective programs identify ways that company policies and company traditions encourage wellness.
• Effective programs work at the group and organization level to build support for healthy lifestyle choices.
• Effective programs set clear target objectives and goals for the health improvement of the worksite.

An initial health screening can include a survey of staff members’ interests as part of the assessment. Effective wellness programs are designed to meet the needs and interests of the staff members. The information you need to get from a survey is dependent upon the scope of your program. A sample survey can be obtained in the HOPE Publications Web site. If you plan to adjust this sample survey or advance your own survey, keep the following hints in mind:

• Ask mostly closed-choice questions, especially if you will be sending the survey to a sizable number of workers. Closed-choice questions offer specific choices and are easy to tabulate. You may want to use a computer for data entry and analysis.
• Invite comments, opinions and recommendations, or ask open-ended questions at the end of the survey. Open-ended items are more difficult to summarize.
• Include a brief explanatory cover letter with the survey with the signature of the organization president. Make sure to include a statement about confidentiality and anonymity.
• Ask a group of representative staff members to review the survey before it is distributed. Find out if the questions will be understood by staff members and will not be objected to.
• Include demographic information at the beginning or end of the survey. Consider various ways that you might analyze the responses by demographic characteristics (gender, age, shift, site, department, etc.).

When considering who should get the survey, a simple rule is if you have under 500 employees, everyone should receive one. The public relations benefit of everyone receiving a survey can be valuable. Over 500 employees, a sample of the work population will suffice. A sample saves on costs and time. You may want to consider paying a statistician to determine an appropriate sample size for your worksite.

Needs surveys are confidential and anonymous; they do not request information that may identify a person.

Getting support from management is crucial to the success of the program.

One way to do this is to survey managers (see forms) and conduct interviews with decision-makers in the organization. You can use the surveys here or make up your own. If you decide to do your own, keep the survey short. It shouldn’t take more than ten minutes to complete.

The interview process can also serve as a means of educating management. Offer concise fact sheets on the benefits of wellness programs for management. When surveys and interviews are completed, tally the surveys and write brief summaries of the interviews. Offer these reports to management.

Once completed present a brief executive summary to management. Highlight a few interesting findings that can be used immediately to make decisions about the program.

Utilize charts and graphs to make your points. Prepare a detailed report for Company Wellness Program Committee members itemizing each response. Offer a short article about the survey in the organization newsletter.

The higher the response the more valid and reliable the results. A minimum response of 40% to 50% is acceptable.

Comprehensive Company Health Promotion Programs involve all staff members, deal with all major health risks, offers choices, and target both the staff members and the workplace environment; offer periodic assessment of its outcome.  Comprehensive Company Health Promotion Programs emphasize follow-up and offers reinforcement for the employee as long as he/she is employed. Studies have shown this approach to be highly thriving. Key components are planning, implementation, and assessment.

Planning comprehensive Worksite Health Promotion Programs involve performing a needs and interest assessment, appointing a Worksite Health Promotion Program Committee, selecting wellness providers, setting objectives for the corporate wellness program, marketing/promoting the program, and establishing procedures to ensure confidentiality.

Implementation of comprehensive Worksite Wellness Programs consist of five major tasks:

1.   Health screening and referral
2.   Follow-up and counseling employees
3.   Follow-up with physicians
4.   Health improvement programs
5.   Organizing workplace-wide activities.

Evaluation involves monitoring Workplace Health Promotion Programs to find out if it is working and to help you refine it. Measuring success shows what you have achieved, helps justify expenditures, and supports information for management to support continued programming.

Initially introduced by Halbert Dunn in the 1950’s, wellness became a popular buzzword during the late 1970’s and received considerable academic attention in the 1980’s.  Workplace Health Promotion Programs for staff members became more widespread during the following decade, and credible evidence for their economic viability began to be published.  There have now been over 100 published studies on this topic and a number of systematic reviews.

Health risks increase costs.  Medical Insurance costs escalate with both age and number of risks present.8,10   The number of risks is also strongly related to sick time absenteeism, Worker’s Compensation costs, short-term disability, and reduced work rate (”presenteeism”).

Early Workplace Health Promotion Programs were relatively basic and typically produced a return on investment of less than one dollar for every dollar invested operating the program (ROI = <1:1).8 Such programs might be characterized as "fun-oriented".  Participation is entirely voluntary, and there is no particular focus on the reduction of specifically identified elevated risks.  Interventions and activities are not personalized, and there is no emphasis on the management of health expenditures.  These programs are typically site-based only, lack options to address all of the major behaviorally-related health risks, and lack multimodal presentation.  Minimal or no rewards and incentives are given to staff members for participation, and services to spouses and family members are not available.  Most such programs lack meaningful assessment.  

More conventional programs are "activity-oriented" and have determined an ROI of between 1:2.5 and 1:3.5.8 These programs may have a greater emphasis on health and risk reduction, even though the efforts are relatively broad and not personalized.  They may have some generalized emphasis on health cost management, even though not necessarily aimed at specific high risks.  Most are site-based and voluntary, with spouses included only rarely.  Modest rewards and incentives may be utilized to promote participation.  Formal evaluation may be weak.

The newest and most economically viable programs are "results-oriented" and exemplify the health and productivity management model.  These programs consistently produce return rates of 1:4 or greater within a 12-24 month period.8   Such programs are strongly focused on the reduction of specifically identified elevated risks and the management of health expenditures.  They are generally voluntary, but use strong monetary and other incentives and rewards to reward participation.  They are multi-component in nature (address all major risks), and have both workplace and virtual modalities of operation.  The interventions are highly targeted and individualized, and available to spouses as well as staff members.

For businesses, the expense of providing health insurance for their employees is of great significance.  Those expenditures have been increasing at yearly rates between 6% and 14%. Chapman's 2007 systematic review stated an average reduction in health care expenditures of 26.5% as a result of Company Wellness Programs.  His review covered 60 of the most scientifically valid studies, with an average of 3.77 years of study.

Absenteeism due to illness is another cost driver.  Chapman's review reports an average decrease in sick leave of 25.3%.   Cost for Worker's Compensation was reduced by 40.7%, and disability costs by 24.2%. There is also an emerging literature on the costs of presenteeism (reduced work rate).11,13  In one study, every risk reduced through a wellness program yielded a 9% decrease in presenteeism (and a 2% decrease in absenteeism).

Some employers have achieved a zero percent growth in medical care costs across at least brief periods of time.10  Doing so requires 90-95% participation of the employee population in focused wellness drives, with 75%-85% of the workers falling into the low risk category.10  Although robust efforts to lower the risk status of those in moderate or high risk categories must be made, the needs of currently healthy workers must be addressed as well to avert increases in risk-status.

Given the size of the federal workforce, valuable cost savings in the government's contribution to health insurance premiums for workers might be achieved if a majority of that population were participating in active wellness programs.  Similarly, improvements in absenteeism, worker's compensation, disability, presenteeism, and turnover as a result of robust Employee Wellness Programs would yield substantial fiscal benefits for the government.

References

1.   Aldana, Steven G.  (2001)   Financial Impact of Corporate Health Promotion Programs:  A Comprehensive Review of the Literature.   Am J Health Promotion 15(5):296-320.
2.   Chapman, Larry.  (1998)   The Role of Incentives in Health Promotion.  The Art of Health Promotion  2(3):1-8.
3.   Chapman, Larry.   (2003)   Biometric Screening in Health Promotion:  Is it Really As Important as We Think?  The Art of Health Promotion  7(2):1-12.
4.   Chapman, Larry.  (2005)   Meta-Evaluation of Worksite Wellness Programs Economic Return Studies: 2005 Update.  The Art of Health Promotion, July/August, 1-15.
5.   Chapman, Larry.   (2006)   Employee Participation in Employee Wellness Programs and Employee Wellness Programs:  How Important are Incentives, and Which Ones work Best?   North Carolina Medical Journal   67(6):  431-432.
6.   Chapman, Larry, Lesch, Nancy, and Passas Baun, Mary Beth.   (2007)   The Role of Health and Wellness Coaching in Employee Wellness Programs.   The Art of Health Promotion, July/August, 1-12.
7.   Chapman, Larry.  (2007)   Proof Positive:  An Analysis of the cost-Effectiveness of Job Site Wellness.  Northwest Health Management Publishing, Seattle, WA.
8.   Chapman, Larry.  (2007)   An In-Depth Look at the Economic Evidence for Rewarding Health Behavior Change.   Workshop presentation at the World Research Group “Rewarding Healthy Behaviors for Health Plans and Employers” Conference, Orlando, FL, January 23-24.
9.   Edington, Dee.   (2001)   Emerging Research:  A View from One Research Center.  American Journal of Health Promotion 15(5): 341-349.
10.   Edington, Dee W.  (2007)   Health Management as a Serious Business Strategy.  Presentation at the World Research Group “Rewarding Healthy Behaviors for Health Plans and Employers” Conference, Orlando, FL, January 23-24.
11.   Pelletier, Barbara, Boles, Myde, and Lunch, Wendy.  (2004)  Changes in Health Risks and Work Productivity.   Journal of Occupational and Environmental Medicine, 46(7): 746-754.
12.   Pelletier, Kenneth R.  (2005)   A Review and Analysis of the Clinical and Cost-Effectiveness Studies of comprehensive Health and Disease Management Programs at the Job Site: Update VI 2000-2004.  JOEM 47(10)1051-1058.
13.   DeVol, Ross, Bedroussian, Armen, et. al.  (2007)  An Unhealthy America:  The Economic Burden of Chronic Disease.  Report released by the Milken Institute.   www.milkeninstitute.org.
14.   Partnership for Prevention.  (2008) Investing in Health:  Proven Health Promotion Practices for Workplaces.   http://www.prevent.org/images/stories/2008/investinginhealth_finalfinal.pdf.