In tEWn

At some point in every health educator’s life, someone, frustrated by the fact that none of the seemingly endless choices of health risk appraisals on the market are the perfect fit for your organization, will suggest, ”Why don’t we develop our own HRA?” When you hear this, run the other way.

Unless your organization has expertise in epidemiology, has a readily available source of frequently updated mortality databases that include diverse populations, and has a high level of expertise in questionnaire design, preventive health, chronic disease, health communications, medical cost prediction, productivity measurement, and health behavior theory, it has little chance of being able to create an effective health risk appraisal.

Unfortunately, when someone casually proposes creating your own health risk appraisal (HRA), it belies a gross oversimplification of what an HRA is-or, at least, what it was originally intended to be.

Too often, people who don’t know better assume that an HRA is a simple, straightforward questionnaire — something you could slap together on SurveyMonkey.com in half a day.

Indeed, there are plenty of good reasons to conduct simple health questionnaires, but let’s not confuse surveys with instruments scientifically designed to assess health risk.

Definitions of HRAs differ. The Agency for Healthcare Research and Quality (AHRQ), in their technological assessment of HRAs published in 2011, captured the prevailing definition, emphasizing the difference between HRAs and simple health questionnaires:

“In health promotion, most observers agree that HRAs involve more than the collection of health information. HRAs are techniques or processes of gathering information to develop health profiles, using the profiles to estimate future risks of adverse health outcomes, and providing persons with feedback on means of reducing their health risks.”

It’s “using profiles to estimate future risks” that will make homemade health risk appraisals a particularly ambitious endeavor, as it requires not only algorithms connecting HRA responses to mortality databases — most commonly, databases that originally were developed and scientifically updated by the CDC and the Carter Center of Emory University — but those algorithms should factor in the severity of risks and how multiple risks and risk-related behaviors (such as unhealthy eating, sedentary lifestyle, and tobacco use) interact with each other. Try doing that on SurveyMonkey.com!

The AHRQ went on to further delineate HRAs as including three specific components:

1. Participants provide self-reported information to identify individual risk factors for disease;
2. Participants receive individualized health-related feedback based on the information they provided;
3. Information collected is used to give participants at least one recommendation or intervention to promote health.

We employee wellness professionals have contributed to the oversimplified perception of HRAs. We have almost universally shifted away from calling them health risk appraisals (or health risk assessments, which aptly described what HRAs supposedly do (namely, assess health risk). Our fear that the name was too negative and our need to differentiate the abbreviation, HRA, from the growingly popular health reimbursement accounts, led to new names. Most commonly, health risk appraisals have been dubbed health assessments (HAs) or something like that.

The problem with calling HRAs health assessments is that these tools, as we know and love them (or hate them), do not assess health. They assess risk related to future health - or prospective health. (HRAs, indeed, were originally promulgated by the Society for Prospective Medicine before it was incorporated into the Institute for Health and Productivity Management.)

If we misrepresent health risk appraisals as health assessments, we should not be surprised that many employers and employees are, as we’ll see in a future post, feeling short-changed by the value of HRAs. And we also should not be surprised when the boss asks us to create a new HRA tool by the end of the day.

The fast-growing health and wellness vendor, Redbrick Health, commendably published their process for developing their own HRA . Their process may not be perfect, but it can be instructional for those who may naively be tempted to whip up a home-grown HRA. Read Redbrick’s article, including the table with details on how responses to questions within 15 domains were used to attribute risk status and the table showing the relationship between the Redbrick HRA and the “gold standard question sets” used to validate their tool. Remember, kids: Don’t try this at home.

It’s ironic that even Redbrick, when communicating to consumers, chooses to call their tool a Health Assessment, as they demonstrate in their article full knowledge of an HRA’s role (and they correctly refer to it as an HRA when addressing the industry) :

An HRA is not a ‘diagnostic’ tool, rather it is an instrument that can assist in categorizing individuals into risk groups based upon their responses… In essence an HRA is triaging respondents so that those individuals considered to be at increased risk in specific areas can receive further assessment and intervention as necessary.

Redbrick, in a blog post, states “absolutely” that HRAs do, indeed, “really help identify actionable health risks and targeted solutions.”

In the next few posts, we’ll explore whether the evidence confirms whether HRAs do what they are purported to do.

[This is the second post in a series about health risks and health risk assessments.]