Health risk

A health risk assessment (also referred to as a health risk appraisal and health & well-being assessment) is one of the most widely used screening tools in the field of health promotion and is often the first step in multi-component health promotion programs.

A health risk assessment (HRA) is a health questionnaire, used to provide individuals with an evaluation of their health risks and quality of life. Commonly a HRA incorporates three key elements – an extended questionnaire, a risk calculation or score, and some form of feedback i.e. face-to-face with a health advisor or an automatic online report.

The Centers for Disease Control and Prevention define a HRA as: “a systematic approach to collecting information from individuals that identifies risk factors, provides individualised feedback, and links the person with at least one intervention to promote health, sustain function and/or prevent disease.”

There is a range of different HRAs available for adults and children. Some target specific populations. For example, in the US, Medicare HRAs ask seniors about their ability to perform daily activities. Medicaid assessments ask questions about health-care access, availability of food, and living conditions. Most HRAs capture information relating to:

The main objectives of a HRA are to:

In the US, HRAs used as part of the Medicare Annual Wellness Visit help identify issues important to a senior’s health and well-being. HRAs used as part of Medicaid enrollment help identify individuals with health problems that need immediate attention.

The original concept of the HRA can be traced back to the decision by the assistant Surgeon General of the United States to conduct a study to determine probable 10-year lifespan of individuals based on lifestyles and predisposed conditions. The project, led by Lewis C. Robbins, MD, of the Public Health Service, was the Framingham study. The study was based on in-depth longitudinal studies of 5,000 families in Framingham, Massachusetts, that continues to this day under funding from the National Institutes of Health. Dr. Robbins left the Public Health Service and joined Methodist Hospital in Indianapolis where, working with Jack Hall, MD, he developed the first set of health hazard tables. This culminated in the publication of How to Practice Prospective Medicine in 1970 – a guide for practising physicians, which outlined the health risk assessment questionnaire, risk computations and patient feedback strategies. It wasn't until 1980, when the Centers for Disease Control and Prevention released a publicly available version, that the HRA became widely used, particularly in workplace settings. Health & Welfare Canada reviewed How to Practice Prospective Medicine and created a mainframe version of the book. The Centers for Disease Control became aware of this product and adapted it to the newly available personal computer. When Prudential Life Insurance also took an interest and asked to fund an update of the program, the CDC, which could not accept private project funding at the time, transferred ownership to the Carter Center at Emory University where it was updated from 1986-7. The transfer and subsequent program were managed by Dr. Ed Hutchins who had worked on the HRA in positions at the University of Pennsylvania and Charlotte-Mecklenberg Hospital. At Charlotte Mecklenberg, he secured a contract with the World Health Organization to create a mainframe product that could be used on an international basis. The HRA was managed as a not-for-profit product. Copies were distributed to every state health department and liaisons were assigned to each to work with their staffs to evaluate related data. Over 2,000 copies of the software were distributed to users who requested it and approximately 70 copies of the code were provided to for-profit companies that were interested in developing proprietary products. This proliferation coincided with the rapid growth in interest in corporate health promotion programs as awareness developed on health risks and for-profit vendors monetized the programs. The Carter Center's interest shifted to Africa and Dr. Hutchins founded the Healthier People Network (HPN) which in 1991 to continue the work. HPN raised funds to support the HRA but additional funding was not forthcoming from government sources. As a result, the Carter Center and HPN could not underwrite basic supporting activities such as annual conferences and, over time, the State-based liaison network and associated intellectual capital atrophied as programs lost funding and liaisons moved on. The use of HRAs and corporate wellness programs has been most prevalent in the United States, with comparatively slower growth elsewhere. However, there has been recent strong growth in corporate wellness outside the US, particularly in Europe and Asia.

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