A number of methodological concerns and certain dimensions relevant to future development are generated in the above research: 1. The issue of test reactivity is especially critical in health risk appraisal instruments, since more advanced tools are designed to stimulate the recipient to take actions that might alter post-test results. Therefore, research studies using health risk appraisals need to control for the interaction effects of testing. Since health risk appraisals are reactive, the interaction of test effects with other experimental treatment (e.g. counseling) cannot be handled by use of non-reactive measures, as methodologists frequently suggest. 2. A second major threat to validity is the issue of experimental mortality. The clients who complete the health risk appraisal instrument are usually assumed to be self-motivated. Where engaged in large scale trials, however, their participation may be coerced at the outset but not enforced throughout the course of the study. Because of this some studies have a high proportion of dropouts. 3. Where this has not been the case, a third threat to validity, selectivity, is often a paramount concern, inasmuch as the populations who have subscribed to the instrument under their own motivation may be already pre-selected as very low risk individuals. In light of the paucity of controlled studies using health risk appraisals, it is difficult to draw conclusions regarding the state of the art. In summary, some general dimensions of the activity surround the development and use of health risk appraisals are: 1. The health risk appraisal appears to be more effective in motivating change with older rather than younger individuals. 2. Individuals given a health risk assessment within a supportive educational process do better than individuals exposed only to the results of a health risk appraisal. 3. Individuals given only a health risk appraisal and results without supportive education do better than individuals given no health risk appraisal. 4. Research participants and users of the instrument are, in almost every study, a self-selected group and appear to be healthier than the general population. One might question whether they are the more motivated population.