Faghri, Pouran D. MD, MS; Blozie, Erika MS; Gustavesen, Sara MS; Kotejoshyer, Rajashree BA
* Review the characteristics of and rationale for the use of health risk appraisals (HRAs), including evidence for their effectiveness in promoting change in health behaviors.
* Describe the Transtheoretical Model, or stage of change model, with special reference to its use in studies of tailored information to promote health change.
* Outline the results of the new study, including the comparative effectiveness of HRA with and without tailored consultation and the implications for occupational health practice and research.
Worksite health promotion programs have seen an upward trend in the last decade due to significant increases in health care cost, which puts the burden for covering these costs on both the employers and employees.1,2 Those with chronic conditions such as overweight and obesity have been reported to incur higher health care cost. For example, the cost associated with overweight and obesity in year 2000 was estimated to be $117 billion, and it was projected to increase to $127 billion in 2004.3,4 This cost is associated with increased health care expenses, absenteeism, lost productivity, restricted activity, sick days, and other indirect medical costs.3 Obese individuals spend approximately 36% more than the general population on health services, and 77% more on medications.3,5 These impacts result in 20% of the population accounting for 80% of America's health care costs. Of equal importance to employers is the fact that the group accounting for no to low health care costs, if overlooked, will drift into the population that accounts for high health care costs.6
Because a large proportion of the population is employed and spends approximately two third of their waking hours at work,7 addressing health issues at work and increasing awareness could be a way to reach much of the population at high risk for developing chronic condition and ultimately keep health care costs low.
Worksite health promotion programs consist of activities that are designed to enhance employees' fitness, health, and overall wellness.8 Advantages from the employees' standpoint are many; having a health promotion program at the worksite is convenient, accessible, often less expensive, and also offer social support from friends and coworkers, and may provide environmental support for behavior change. From the perspective of employers, worksite wellness programs may increase productivity and improve employee morale, recruitment, and retention. The return on investment models have shown monetary savings from increased productivity, decreased sick days, and reduced health care costs following introduction of worksite wellness programs.8,9 Medical costs and costs due to loss of productivity are high and continue to grow.10 Two large threats to productivity costs are absenteeism (not going to work due to sickness) and presenteeism (going to work even during sickness but not producing the same quality and quantity of work that would have been done if the employee was in good health). These threats could be overcome by improving employee's health.
Health risk appraisals (HRAs) are commonly used tools to assess individual's behavior and to educate individuals on their health risks and promote behavior change.11–15 These instruments typically collect epidemiological risk factors from each person and then calculates their risk for certain conditions based on general population at risk. The provision for HRA is the belief that by providing an individual with information about their risk for disease and possible death from such disease, the person will change behavior. Nevertheless, research on the evidence of HRA efficacy is weak. One reason presented in the literature is that HRA alone may not provide adequate information to make the needed changes. On the other hand, HRA supplemented with a tailored counseling (TC) session, which include information specific to the individual's response to the questionnaire, interest in behavior change, and perceived benefits and barriers, have been shown to be effective in promoting change for certain health behaviors, including dietary fat intake and aerobic exercise.11 Controlled studies have shown that when the HRA is supplemented with counseling by a health care provider, it will be much more effective than the HRA alone in changing individual's attitude toward behavior and motivate him or her to change.16
Rimer et al17 studied the impact of tailored interventions in women on knowledge about breast cancer and mammography, accuracy of breast cancer risk perceptions, and use of mammography. The results showed that women who received a combined intervention of tailored print booklet and tailored telephone counseling were more likely to have had mammograms 12 and 24 months later than women in the usual care group or those who received only tailored print materials.
Kreuter et al18 evaluated the tailoring effects through a randomized study in which participants received weight-loss materials that were tailored to the individual or an American Heart Association brochure or American Heart Association content formatted to look like tailored materials. The results showed that individuals who received tailored information had significantly more positive thoughts about materials indicating intentions to make behavioral changes than those who did not receive tailored materials. They concluded that tailoring of health information can significantly improve and stimulate pre-behavioral changes such as self-assessment and intention.
Furthermore, informing individuals about their lifestyle risk factor and increasing their belief to change the unhealthy behavior is important for change to happen. Prochaska and DiClemente's Transtheoretical model (TTM), or stage of change (SOC) model has been applied to multiple behaviors and is effective in assessing lifestyle behavior.19–21 This theory tries to explain “how” rather than “why” individual engage in certain behavior and how change could happen.22–24 Based on this theory, there are five distinct stages that individual go through to change, and therefore it offers 10 processes to make change. Components of these process include self-monitoring, goal setting, self-efficacy, and self-confidence.19 The five stages are precontemplation (not ready to change), contemplation (thinking about changing in the next 6 months), preparation (thinking about change in the next 30 days), action (have been practicing the new behavior for the past 30 days but less than 6 months), and maintenance (have been practicing the new behavior for the past 6 months).25 The five stages of the TTM represent ordered categories along a continuum of motivational readiness to change a problem behavior and provide guides for many intervention programs.25,26 Therefore, most of the behavioral intervention addresses self-monitoring, goal setting, self-efficacy, and self-confidence.19 For example, Bock et al27 conducted a study examining the use of interventions that were tailored to match participants' SOC. Participants in the individually tailored interventions were given individually tailored reports that consisted of preplanned counseling messages and self-help manuals, which matched the individual's TTM stage of motivational readiness for change.21,27 Results from this study indicate that exposure to information tailored to an individual's SOC is an effective way to increase participation in physical activity.
The purpose of the present study was to evaluate the effectiveness of the HRA alone and the HRA supplemented by a TC session in increasing employees' awareness of their health risk factors, physical activity, healthy eating habits, and healthy weight management in the 6-month follow-up HRA. Furthermore, this study evaluated and compared subjects' movement through SOC for physical activity, healthy eating habits, and weight maintenance between HRA baseline and follow-up.
This was a pre-test post-test control group design consisting of two groups of worksite employees who self-selected either into the experimental group (HRA and with tailored consultation by a health professional) or the control group (HRA without consultation).
Sixty employees, of which 14 were men (mean ± SD, 47.0 ± 10.4 years) and 46 were women (mean ± SD, 43.9 ± 10.2 years) were recruited from a public sector agency consisting of 650 employees. Participation in this program was voluntary and all subjects signed an informed consent approved by the university and worksite Institutional Review Boards at the beginning of the study. Table 1 depicts characteristics of the subjects.
Health Risk Assessment Questionnaire
A 39-question instrument, designed by Wellsource Inc (Clackamas, OR, USA), was used to assess health perception, family health history, personal health history, current symptoms, bodily pain, health limitations, emotional problems, social activity, limitations of daily activities, frequency of aerobic, stretching and strength building exercises, frequency of eating breakfast, snacks, salt, breads and grains, fruits and vegetables, and fat intake. The questionnaire also assesses the number of drinks taken per week, use of medications, smoking status, chewing tobacco status, coping status, number of stress signals, frequency of healthy and unhealthy emotions, hours of sleep, job satisfaction, social support status, safety, sick days, women's health issues, and stage of readiness for change in the areas of physical activity, good eating habits, avoidance of tobacco products, healthy weight maintenance, handling stress, and living an overall healthy lifestyle. The Wellsource software program calculates the fitness score, nutrition score, personal wellness profile (PWP score/overall health score), high-risk factors, good health indicators, and SOC scores (participation in physical activity, healthy eating habits, healthy weight management, and maintaining an overall healthy lifestyle) based on individual's response to the HRA questions.
Fitness score is based on the responses to questions reporting the frequency of fitness activities; nutrition score is based on intake of fiber, fat intake, breakfast, snacks, and food guide pyramid with the food guide pyramid weighted as four and dividing by eight.
Personal Wellness Profile (PWP Score/Overall Health Score of 100)
The profile is developed for each individuals based on the following criteria to determine the overall wellness score after determining the maximum score based on the number of good health indicators. The criteria are excellent: a minimum of 75 and 14 to 15 good health indicators; doing well: a minimum score of 50 and 12 to 13 good health indicators; needs improvement: a maximum score of 49 and 8 to 11 good health indicators; caution: a maximum score of 24 and 0 to 7 good health indicators. The number of good health indicators and high-risk factors is taken into consideration when determining overall health scores. If a participant has 14 to 15 good health indicators but has any one of the eight high-risk factors, the maximum score he or she can achieve is a 74 and he or she will be categorized in the doing well category. If a participant has 14 to 15 good health indicators but has any two of the eight high-risk factors, the maximum score he or she can achieve is a 49 and he or she is in the needs improvement category. There are 15 good health indicators scores that include aerobic exercise, nutrition, cholesterol, blood pressure (BP), overall heart health, overall stress, alcohol, seat belt, overall safety, happiness, and overall cancer score. All the scores are categorized as doing well or excellent. Other categories include sleep 7 to 8 hours always or most days, and having less than 5 sick days a year. The eight high-risk factors include LDL level or total cholesterol is ultrahigh, HDL level is low, BP is high, cigarette smoker, body composition is underweight, overweight or obese, heart health is rated in the caution category, alcohol score is rated in the caution category, aerobic exercise score is rated cautionary.
Other Dependant Measures
Weight was measured using a SECA 841 scale in pounds with 0.2 lb graduations. The same scale was used by all participants. Waist and hip were measured using a calibrated measuring tape. Resting BP was measured using sphygmomanometer after 15 minutes of rest in a chair. Body mass index was calculated by the Wellsource software using the height and weight. Classification of measurements was determined by the use of the National Cholesterol Education Guidelines. Finally, a small blood sample to determine the participants' level of total cholesterol in milligrams per deciliter and blood glucose in milligrams per deciliter was taken by trained nurses through finger prick.
The program was announced through emails, newsletters, and posters that were distributed at the worksite. The inclusion criterion was based on willingness of the individual to complete the second HRA in the next 6 months. Sixty participants were recruited and completed both HRA. Following completion of the baseline HRA, participants were given the option to schedule a time for consultation with a health educator to discuss the results of their HRA report. Each consultation was for approximately 15 minutes and consisted of three components: 1) a complete overview of the HRA report and making sure that each participant completely understood the results of the report. Participants were encouraged to ask questions if they did not understand their generated individualized reports, 2) the consultant then asked the participant to identify a health behavior that he or she wishes to improve, and 3) the consultant and the participant create health-related goals to be accomplished by the time of the second HRA (6 months later). The consultations were based on self-monitoring, goal setting, self-efficacy, and building self-confidence.15 These practices were consistent with constructs of the TTM. The construct of self-efficacy was employed by asking subjects to pick the areas in which they felt they are capable of making change. The health educator then spoke to the subject about ways he or she could make improvements, and the subject was able to ask questions about improving this area. This also incorporated the consciousness raising construct of the TTM. The health educator provided new ideas and tips that supported behavior change. Lastly, the subject and the health educator created wellness goals and discussed ways to reach these goals. The self-liberation construct was used to help individual create his or her own health goals. By setting a goal to achieve, the subjects were taking the first steps in the commitment to change. All consultations were conducted by the same health educator to enhance reliability. The follow-up HRA was conducted 6 months following the first HRA for both the experimental (consultation) and control (non-consultation) groups.
Repeated measures analysis of variance were used to determine the within group and between group differences between the experimental group and the control group from baseline to follow-up HRA for fitness score, nutrition scores, and overall wellness scores. Movement through the TTM was determined if a participant recorded a higher stage of the TTM in the post-administration of the HRA questionnaire than on the pre-administration of the HRA questionnaire. A χ2 analysis was used to determine if there were differences between the consultation group and the non-consultation group in terms of the forward movement through the TTM. Spearman rank test was utilized to find the relationship between consultation and SOC scores. For all the statistical analysis, the P-value of less or equal to 0.05 were considered significant.
The age distribution of the study subjects compared to the entire workforce is depicted in Table 2. The differences were not significant, hence the study sample were considered a representative sample of this workforce based on the demographics.
The gender distribution, as depicted in Table 1 shows that the number of male participants was low. This is due to the fact that the majority of employees in this worksite were women (65%). This may limit the generalization of the results of this study.
Significant improvements were seen from baseline and follow-up HRA questionnaire for all study subjects' readiness for change toward nutrition, weight management, overall health, and exercise independent of intervention (P ≤ 0.05). The only significant difference between the two groups was in SOC for exercise (P = 0.04). Figures 1–4 depict the improvements in SOC for exercise, nutrition, weight management, and overall health for all the study participants.
There was a significant relationship between SOC in exercise, (P = 0.043), change in nutrition stage (P = 0.002), and change in weight management stage (P = 0.000), and receiving a consultation in the follow-up HRA.
The PWP scores, which include fitness, nutrition, and overall health, were calculated using Wellsource software. In general, the consultation group had higher scores for fitness, nutrition, and overall health; however, the differences were not significant between groups. Figure 5 represents mean fitness scores of the consultation group and the non-consultation group from the first administration of the HRA questionnaire (pre) to the second administration of the HRA questionnaire (post). Significant differences were found between the pre- and post-fitness score means in all subjects independent of receiving or not receiving a consultation (F = 10.885; P = 0.002). No significant difference was found between the consultation and non-consultation groups. Both groups experienced an increase in fitness scores; the consultation group increased the mean score from 45.47 to 52.41, and the non-consultation group increased the mean score from 34.54 to 44.32 (Fig. 5).
Figure 6 represents the mean nutrition scores of the consultation group and the non-consultation group from the first administration of the HRA questionnaire (pre) to the second administration of the HRA questionnaire (post). Significant differences were found between the pre- and post-nutrition score means (F = 8.097; P = 0.006) for all subjects, independent of receiving or not receiving a consultation. The increases in the mean nutrition score was from 58.06 to 63.53 for consultation group and from 49.57 to 56.46 for the non-consultation group.
Figure 7 represents the mean overall (PWP) scores of the consultation group and the non-consultation group from the first administration of the HRA questionnaire (pre) to the second administration of the HRA questionnaire (post). Significant differences were found between the pre- and post-overall health score means (F = 38.886; P = 0.006) for all subjects, independent of receiving or not receiving a consultation. The mean increases for overall health score from pre- to post-administration was from 47.34 to 62.72 and from 37.11 to 51.18 for the consultation group and the control group, respectively.
Significant differences were seen in the amount of snack foods consumed in both groups from pre- to post-HRA administrations (F = 6.056; df = 58; P = 0.017). Also, significant change was seen in the amount of fruits and vegetables consumed daily by participants in each group between pre- and post-HRA administrations (F = 7.421; df = 58; P = 0.009). The number of days subjects engaged in 20 to 30 minutes of aerobic exercise (F = 8.200; df = 58; P = 0.006) was also improved significantly from pre- to post-HRA administrations.
Participants in the study evaluated the HRA program by completing the additional questions that were included during the second administration of the HRA questionnaire. Eighty percentage of the consultation group agreed that the consultation was effective in helping them identify a health risk to improve on. Ninety-seven percentage of the study sample reported that they would recommend the HRA to others.
HRA is one of the most used tools for promoting healthy lifestyle at the worksites. It is estimated that approximately 15 million Americans have participated in HRA programs at different work settings.11–15 The results of the present study reveal the effectiveness of HRA in making behavior changes in the areas of exercise, diet, and weight management.28,29 Significant improvements were seen in our subjects in terms of movement through the TTM. The results examining the stage of readiness for change in the areas of fitness, nutrition, healthy weight maintenance, and overall health demonstrate that the use of HRA promote forward movement through the TTM. There was a significant difference from baseline HRA to follow-up based on consultation in the area of physical activity (F = 4.019, P = 0.041) but not in other areas. Interestingly, there was a relationship between SOC in exercise, and receiving a consultation (P = 0.043), change in nutrition stage (P = 0.002), and change in weight management stage (P = 0.000). This may suggest that increasing awareness and modifying lifestyle in one area may affect and cause changes in lifestyle in other areas. Implementation of HRA at the worksite has also been reported to be effective in improving health-related behavior by other investigators.15,30 The tailored consultation appeared to promote physical activity and had positive relationship with improving eating behavior and overall lifestyle.31
The use of individual consultations and interventions tailored to the level of an individual's SOC has been demonstrated to improve health behaviors in terms of forward movement through the TTM.11,27,32 Consequently, we did not see improvements in all the categories, one explanation could be the possible differential effects of quality of messages delivered through consultation. Evaluation of the HRA at the end of the program showed 80% agreed the consultation was effective in helping them to identify a health risk to improve on. Ninety-seven percent of all participants reported that they would recommend the HRA to others. Study by Kellerman et al30 found that 8 months after participants had received an HRA and met with a health educator, 93% reported having made changes to at least one health-related behavior. Other studies have shown that the use of HRA in worksite health promotion programs was beneficial.33,34 Our study is in agreement with previous studies and shows that the use of HRA is an effective way to promote healthy behaviors, as demonstrated by significantly different fitness, nutrition, and overall health scores.
Studies also have shown that tailoring the education regarding the unhealthy behavior is more effective than HRA alone. In 2007, Lowther et al19 identified constructs of the TTM specific to each stage to be predictors of behavior change. In our study, attempts were made to individualize the consultation based on individual's stage by following the 10 processes recommended by Prochaska.20 Although we found significant relationship between improving behaviors such as exercise, healthy eating and weight management, and receiving consultation, we also found improvements in other behaviors for both groups irrespective of the intervention. It is postulated that based on previous studies, individuals tend to remember or to read something that is directly addressed to them.35,36 It could be postulated that since the HRA report was directly addressing an individual's risk factors, he or she may have felt more vulnerable and was encouraged to change the unhealthy behavior (conscious rising). On the other hand, tailoring consultation may help identifying barriers and find ways to overcome those barriers. Future studies must recognize ways to maximize the effectiveness of tailoring consultation and distinguish between simple personal feedbacks and tailored behavioral change. Similar results in altering the physical activity, nutrition, and overall health have been reported in a study conducted by Baier et al37 in 1992 in which subjects were able to modify behaviors associated with cardiovascular disease.
We found significant differences between groups in the amount of snack food consumed (F = 6.056; P = 0.017), the number of fruits and vegetables consumed (F = 7.421; P = 0.009), and the number of days subjects engaged in physical activity (F = 8.200; P = 0.006). These results are promising as an indication that tailored intervention to increase knowledge about the intake of fruits and vegetables and decrease consumption of unhealthy food, while increasing physical activity may have protective effects in acquiring some chronic diseases for adults at high risk.38–40
The findings of this study add to the growing body of knowledge on the effectiveness of application of HRA at the worksite as well as tailored consultations. The SOC model may provide a useful framework for conceptualizing the behavior change process and identifying the characteristics to address during the TC. The HRA effectiveness may be enhanced by inclusion of important psychological factors in its assessment and feedback components. The addition of tailored consultation to the HRA is consistent with theories of behavior change and could be postulated that the use of HRA at the worksite is an effective way to promote behavior change, based on significant improvements to TTM SOC and calculated health scores. These results are consistent with previous literature that shows the use of HRA is an effective way to promote risk reduction and the adoption of healthy behaviors.8,11,27,30,41,42 Nevertheless, due to small sample size generalization of this study may be limited. Further studies must consider larger study samples as well as re-administering the HRAs at 12 and 24 months to examine the long-term behavior changes. The benefits of HRA may be greater for those at high risk for developing chronic diseases. Targeting individuals who are unhealthy and have the greater need for the HRA program should be done in future research.
This study was a part of ConnectiFIT worksite health promotion program supported by Center for disease control cardiovascular health program (CDC) and Connecticut Department of Public Health.
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