Anna Martinez, M.A., is a health educator and program evaluation consultant in the Health Behavior Group at HealthPartners health system in Minnesota.
Jeff VanWormer, M.S., is a senior program evaluator at HealthPartners (Minneapolis, MN). He has several peer-reviewed publications on obesity management and currently serves on the editorial review boards of Disease Management & Health Outcomes, and the Journal of Behavioral Analysis in Health, Sports, Fitness, and Medicine.
Nico Pronk, Ph.D., FACSM, FAWHP, is executive director of the Health Behavior Group and vice president of Health and Disease Management at HealthPartners health system, which provides health promotion, disease prevention, and disease management services for worksites and health plans around the country. Dr. Pronk has published extensively in the health-related scientific literature and is currently an associate editor for ACSM's Health & Fitness Journal® and an Editorial Board member of Center for Disease Control and Prevention's Preventing Chronic Disease e-journal. Among other public services activities, he currently serves on the Task Force on Community Preventive Services supported by Center for Disease Control and Prevention and the Interest Group on Worksite Health Promotion at ACSM. Dr. Pronk received Fellow status from ACSM and the former Association for Worksite Health Promotion.
ACTION RESEARCH TO SUPPORT WORKSITE HEALTH PROMOTION
Action research may be best described as efforts related to a dynamic, participatory, voluntary process that seeks to bring together action, reflection, theory, and practice, with the intent to improve processes, outcomes, and impact. Action research can be readily applied to the worksite because it is a place central to the existence of people, is highly valued in their lives, and represents a complex microcosm that does not lend itself easily to controlled experiments. In 1951, Kurt Lewin introduced his field theory that states that the behavior of an individual is a function of both personality and environment. He went on to provide evidence that this premise holds true by showing that leadership styles directly influence productivity and conflict among groups of employees (1). By using an action research model, he was able to initiate positive changes.
In today's worksites, efforts to improve the health of employees are abundant. Central to these efforts are assessments of health risks, typically by way of a standardized Health Risk Assessment (HA) tool. Yet, formal studies or practice-based learnings are lacking. This paper presents the findings of an action research project designed to assess the effectiveness of various levels of incentives and communication strategies on worksite-level HA completion rates. Information from these findings is discussed to help organizations determine the most appropriate HA engagement strategies to use for their company.
THE ROLE OF HEALTH ASSESSMENTS
The assessment of health risks can be accomplished in a variety of ways including biometric screening or safety testing, but HAs are probably the most common method used. An HA is a nomenclature used to describe a self-report tool (survey) that involves a personal assessment of health risks, health status, health behaviors, disease status, and other indicators related to healthy living. Health Risk Assessments are an important component of a comprehensive worksite health promotion effort. It is, however, challenging to generate high levels of participation because it requires time-out of an employee's busy day, the disclosure of private health information, and addressing competing work priorities, among many other potential reasons.
Sufficiently high levels of participation, or HA completion, are extremely important to paint as true a profile of the employee population's health as possible. Unless the participation rate is high, the generalizability of the HA results across the entire work force remains uncertain. As a result, organizations attempt many ways to convince their employees to take an HA, although it seems that completion incentives and communication strategies stand out as the most common general tactics. However, the degree to which these strategies influence HA completion rates is largely unknown. Various companies decide touse strategies that may fit their organization well but may differ from other companies in intensity, duration, and overall approach.
HEALTH ASSESSMENT PROJECT OVERVIEW
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This project used an ecological study design, whereby companies (vs. individuals) were used as the unit of analysis. Data were considered from the HealthPartners health plan HA database and included only companies with at least 500 participants who completed the HA in 2006.
The HealthPartners HA is a questionnaire consisting of 100+ items designed to identify health improvement opportunities and highlights pertinent risk factors and opportunities for risk reduction for those who complete it. It also identifies individuals with active chronic diseases and those at high risk for developing diabetes and heart disease.
The outcome of interest was the company-specific HA completion rate (i.e., the number of employees who completed an HA in 2006 divided by the total number of employees eligible to complete an HA during that same time frame). Two predictor variables were considered: incentive strategy and communication strategy. For each company, both the incentive and completion strategies were scored by two raters as strong, moderate, or weak. For incentives, this determination was based on the estimated monetary value of the incentive. For communication, this determination was based on the frequency and timing of the communication outreach. Information on incentive and communication strategies was obtained from account managers.
Two analyses were conducted. First, a combined incentive/communication score was calculated for each company, and the HA completion results were plotted in a scatterplot. Second, companies were pooled into weak, moderate, and strong groups (for both incentives and communications) and plotted using a bar graph. A Pearson correlation and significance test was calculated for both analyses.
Eleven companies were included in the analysis. The number of eligible employees at each company ranged from 535 to 14,000. The overall health of each company varied as well, with the percentage of HA completers at high risk (predisease) and/or with active disease ranging from 12% to 41%. Descriptions of the communication and incentive strategies are summarized in the Table.
TABLE Population Siz...Image Tools
When graphically depicted, a strong and statistically significant positive relationship between HA completion rates and the incentive/communication score emerged (Figure 1). Similarly, there also was a strong and statistically significant positive correlation between HA completion rates and pooled incentive and communication strategy groups (Figure 2). These two figures collectively indicate that as the incentive and communication strategies become more intense, HA completion rates increase accordingly.
STRATEGY AND PROGRAM APPLICATION
At the aggregate level, HAs can help worksite health promotion practitioners and decision makers target resources appropriately to help reduce health risks and optimize worker health. Convincing a large group of employees to take an HA, however, remains a challenge. Health Risk Assessment completion rates seem to be influenced by the strength of the incentive and communication strategies. Specifically, HA completion rates ranged from approximately 50% for weak incentive/communication strategies to approximately 90% for strong incentive/communication strategies.
Strong communication strategies require that the message is delivered frequently using many different methods because people access information in various ways and at various times. Doing this likely helps to create word of mouth among coworkers and increases general awareness. Common methods for communication can include mass emails, posters, pay stub inserts, cafeteria tent cards, invitation letters, designated intranet sections, and perhaps most importantly, personal announcements from familiar staff at localized (usually departmental) meetings.
Interestingly, small companies had higher HA completion rates relative to larger companies. This may be because the communication strategies can be delivered more consistently and reliably to almost all of the employee population. In contrast, larger companies may find it difficult to engage in the same communication strategy across all sites. The particular strategy selected should be based on experience with other critical employee communication methods that have worked well in the past.
Larger incentives generally seem to increase HA completion rates as well, although there may be a point at which the returns diminish substantially. Because health care is such a significant cost for most employees, incentives related to health-care expenditures seem to work particularly well, especially if there is a fair amount of health risk in the population. Some examples of health care-related incentives might include copay reductions, deductible reductions, and deposits into a health savings account. Eligibility for health plan coverage also was a highly effective strategy. Organizations should consider this approach carefully though, because, in the mind of some employees, this functions more so as a disincentive not to take a HA (vs. a reward for taking a HA).
A combination of incentives and communication strategies gives an organization an excellent chance of recording HA completion rates that are high enough to allow for valid inferences about the worksite population. Several caveats should be mentioned, however, in the interpretation of these results. Only a small number of Minnesota-based companies were available for the analysis; therefore, it is unclear how representative the sample was for all U.S. companies. Also, only group-level variables were examined using a correlation approach. As such, the results do not imply cause and effect and may not be applicable to individual-level applications. There was a wide range of HA completers at high-risk (predisease) and with active disease (ranging from 12% to 41%), along with logistical factors such as location, type of company, and ability to take the health assessment during work hours. At the end of the day, companies need to determine what works best for their employees but can certainly consider the implications of learning from this type of action research project.