EMS & Health Promotion

     As an integral part of the overall healthcare system,¹ EMS systems and their underlying missions are being reshaped by evolving market forces, expanding needs, changing community expectations² and a broadening perspective of health.^3,4 This article discusses potential roles for such reshaped EMS systems within public health, specifically in health promotion, using a hypothetical example of a target issue—aging—to demonstrate the opportunities, identify the barriers to be overcome and suggest possible solutions to those barriers.

EMS AND PUBliC HEALTH
     From a public health perspective, being healthy is more than simply not being sick. The constitution of the World Health Organization says, "Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity."⁵ This perspective of health—along with the recognition that health is a basic right of all people, is necessary for both the economic and social development of societies, and has global implications—has been reconfirmed by a series of consensus conferences.^3,6,7 But can such a holistic view of health be relevant to EMS?

     EMS is not solely about delivering medical care to individual patients. It is also part of both the larger public safety infrastructure and the public health infrastructure.^1,2,8 By its nature, EMS is part acute medical care, part public health, part mental health, part emergency service, part community service, part social service, part transportation service and more. Further, EMS professionals see firsthand—in people's bedrooms and living rooms, in their cars and in their workplaces, in neighborhoods and communities—the interactions between individuals, their health, economic and social circumstances, community structure and resources, and environmental factors.² Indeed, a holistic view of health is as relevant to EMS as to any health discipline—maybe more relevant.

     Recognizing the "dissimilar but complementary" nature of the services provided by EMS and by public health professionals in the United States, a working group assembled by the National Highway Traffic Safety Administration (NHTSA), the National Association of EMS Physicians (NAEMSP) and the American Public Health Association (APHA) identified eight potential benefits from combining EMS and public health efforts as listed in Table I. Ultimately, the participants concluded, "The bottom line is that a collaboration of EMS and public health will lead to improved health in the community."⁹

Table I: Benefits of Collaboration Between EMS and Public Health
     Reduced healthcare costs: "A greater range of resources and options for delivery of services, offering improvements in efficiency and reduced costs."

     Greater accountability: "Reduce uncertainty about roles and improve accountability for community health."

     Education: "A simplified delivery system and improved community outreach."

     Coverage: "Combining the unique surveillance and access resources…improving reach into underserved areas and populations."

     Security and stability: "Assess the relative value of health services and allocate healthcare funding to provide the greatest value to the community."

     Access: "Extend the reach of EMS and the mobility of EMS to enhance the delivery of public health services."

     Adaptability: "A combined EMS and public health system will be capable of quickly detecting and responding to community health needs."

     Improved health: "Improved responsiveness, greater efficiency and enhanced effectiveness will lead to improved health in the community."

     Benefits identified by the NHTSA/NAEMSP/APHA Working Group on EMS and Public Health⁹

EMS AND HEALTH EDUCATION
     Health education can be a complicated endeavor. Presumably, better informed people avoid unhealthy behaviors, opting instead for healthy behaviors. In fact, it is not that simple: Well-informed people often continue to smoke, eat fat-laden foods and exercise less, drink and drive, and engage in a long list of other unhealthy behaviors. Health behaviors—those actions that otherwise healthy people take in order to stay healthy—are influenced by a number of things, including social and demographic factors (such as marital status, age, sex), peer influence (family, friends, coworkers), perceived or experienced symptoms of disease (or the absence of any symptoms) and psychological or emotional influences (such as stress).¹⁰ Providing information alone is not enough; it is also necessary to provide "encouragement of attitudes that increase the likelihood that health knowledge will be transformed into personal action."¹¹

     Incorporating health education and an understanding of health behaviors into an EMS system's mission can contribute to the everyday mission of providing patient care. EMS providers who recognize the complexities of behavior change will have a better understanding of why the emphysema patient hasn't stopped smoking or the heart failure patient still eats potato chips by the bag, and will provide better, nonjudgmental care. In some circumstances, an EMS provider who is knowledgeable about health behavior change theory might even be able to make a brief intervention during a patient encounter.

EMS AND HEALTH PROMOTION
     Health promotion is more than health education. Health promotion takes the holistic view: Health is not just wellness or healthy behavior, but rather is interdependent with economic, social and environmental well-being.⁵ This interdependence is a key idea in health promotion: Economic, social and environmental well-being are not only resources that lead to health, but health is also a resource that leads to economic, social and environmental well-being. They are inseparable resources. Health promotion works to give people greater control of their health, to give them greater control of their resources.¹²

     One of the cornerstones of health promotion, the Ottawa Charter, identifies three primary mechanisms for promoting health: advocacy for health and for a holistic view of health; enabling people by creating equity in terms of access, opportunities, resource availability and life skills; and mediation among governmental, industrial, health, community and other sectors of society to increase recognition of, and promote actions that take into account, the interdependent and intersectoral nature of health.⁴ EMS is uniquely situated to contribute to these efforts. As discussed earlier, EMS professionals see the interplay between health, economic security, social status and environmental conditions on a daily basis² and see that those people with the least control over these resources are the ones who suffer most. EMS professionals are also held in high esteem,⁸ and, as a result, are in a strong position to advocate for the holistic view of health. EMS systems offer universal access (anyone can call for an ambulance at any time for any reason) and equitable resource availability (the same equipment and same personnel are dispatched to every "possible stroke" that occurs in a community, regardless of whom the patient is, where the patient lives, or how well insured that patient is), embodying the concept of enabling. Finally, as also noted earlier, EMS systems are inherently intersectoral^1,2 and well-positioned to mediate among and between governmental agencies, businesses, the healthcare industry, nongovernmental organizations, communities and individuals.

     There have already been some EMS-based health promotion efforts, primarily in the area of injury prevention.^2,8,13 One of the earliest and most successful initiatives emerged in San Diego, CA, where, after the tragic drowning of a young boy, a paramedic used EMS system data showing trends in backyard drownings to rally his EMS colleagues into a community education campaign and a series of legislative efforts. The result was a demonstrable reduction in childhood drowning. The experience was the springboard for the EPIC (Eliminating Preventable Injuries in Children) Foundation, which now supports other EMS-based injury-prevention programs and which, each year, presents the most exemplary of those programs with an award.¹³

     The Ottawa Charter outlines a framework of five strategies for health promotion: 1) build healthy public policy, 2) create supportive environments, 3) strengthen community action, 4) develop personal skills, and 5) reorient health services.⁴ These strategies are further explained in the example below.

A (HYPOTHETICAL) MODEL FOR EMS-BASED HEALTH PROMOTION
     The areas in which EMS-based health-promotion activities could be pursued are virtually unlimited. Injury prevention, the needs of the very young and heart disease are just three prominent areas that would be appropriate for EMS-based health-promotion initiatives. Those areas, however, come with the prejudice of work that has already been done and thus biases, based in history, about what role EMS should play. In order to start with a clean slate and get "outside the box," it is useful to consider an example that has important EMS implications, but in which most previous and existing EMS initiatives have concentrated on clinical care: aging.

THE CASE FOR AGING
     The aging population has profound implications for EMS. First, many aged people suffer poor health directly—not just clinical health, but holistic health.^12,14 The elderly constitute a significant proportion of people struggling with disabilities and chronic diseases.¹⁵ They are also a vulnerable population, often economically disadvantaged, socially excluded and living in environments that few would describe as desirable.^12,14 Second, "the elderly consume hugely disproportionate healthcare resources," which are then not available for other potentially more cost-effective health initiatives—including EMS initiatives.¹⁵ Third, of explicit importance to EMS, older people have high rates of ambulance service utilization, and, as the population ages, demand for EMS services will increase dramatically.^16–18 Finally, and of direct importance to all, everyone ages. EMS has a stake in aging.

     It might be argued, paradoxically, that improvements in health are in fact the reason aging is an issue. The increase in life expectancy is attributed, at least in part, to improved health.¹⁵ Here it is important to differentiate between health and life. Health promotion is about maintaining wellness, quality of life and functional ability for as long as possible; it is not about longevity at all costs.

OPPORTUNITIES
     What opportunities exist for EMS-based health promotion activities that target aging? Using the strategies laid out by the Ottawa Charter,⁴ below are some examples of how EMS-based health promotion might target aging, reducing morbidity by empowering people to control their own health:

1.      Access to healthcare is a determinant of health.¹⁴

        In the United States, EMS sees the effects of inequities in access directly: Patients frequently depend on emergency services for what should otherwise be delivered as primary healthcare, sometimes because general practitioners refuse to see uninsured patients or patients covered by Medicare or Medicaid. Even in societies with universal health coverage, however, there are inequities in access to care: Rural areas have fewer health resources than urban areas; the wealthy may still have access to separate, private health services.

        Access to healthcare could be partially addressed through building healthy policy. Building healthy policy means establishing policies that make healthy choices the easier choices; it does not mean passing laws that dictate behavior. EMS could advocate for policies that increase equity in health access, from something as simple as extending office hours on a local level to employment policies that allow "health leave" and not only "sick leave." Enabling access to healthcare not only has immediate effects on the currently aged; access to adequate healthcare for the currently (relatively) young will result in improved health for those individuals (and therefore reduce their demand for EMS) as they become older. The adoption of such policies will require mediation between governments, employers, healthcare providers, insurers and taxpayers.

2.      Transportation is a determinant of health.¹⁴

        People who use public transportation typically get more exercise, and modern public transit systems have less environmental impact than automobiles. People who get more exercise and live in cleaner environments enjoy better health throughout their lives. Efficient public transportation systems also allow the elderly to remain independent once they reach the stage at which driving is no longer prudent. Transportation issues could be addressed by creating supportive environments. Creating supportive environments means recognizing the socio-ecological interrelations between environments and health, and therefore working to develop environments in which people take care of each other, their communities and their natural resources. EMS could advocate for efficient public transportation systems, mediating between transportation departments, local businesses, state Medicaid officials and taxpayers to help them recognize that building and maintaining efficient public transportation enables healthy transportation choices in the young and independence in the aged, which compresses morbidity and serves each of their respective interests.

3.      Social exclusion and social support are determinants of health.¹⁴

        In many areas, particularly rural areas, there are too few assisted-living facilities. As a result, those elderly who cannot live independently are forced to move away from their homes, families and social networks. The precipitous decline in health that is often seen after such a move—and which inevitably consumes EMS resources—is usually attributed to the aging process, with little thought given to the role of social isolation. Social exclusion could be addressed through strengthening community action, which means involving communities in determining and pursuing their health needs and empowering communities to take care of themselves. EMS can work with communities to increase the availability of local assisted-living facilities by advocating for grass-roots action demanding such facilities and by mediating between community organizations, government agencies and corporations that run such facilities, thus enabling the elderly to maintain closer contact with their established social support systems.

4.      Food is a determinant of health.¹⁴

        Lack of food is one problem, but poor food choices are another. The food choices made throughout life cumulatively impact health in later years. Food issues could be addressed through developing personal skills, which means giving individuals the tools they need to control their own health. EMS can help individuals develop better eating habits—not only the elderly, but everyone. EMS can advocate good eating habits, perhaps through sponsoring a community garden; EMS can mediate between school officials and the food industry to ensure that appealing, healthy lunches are available to all children, enabling them to develop good eating habits early in life—habits that will pay off (for both the individuals and the EMS system) when they reach old age.

5.      Reorienting health services is important to all determinants of health.⁴

        Reorienting health services means moving away from a focus on therapeutic intervention and moving toward services that take a holistic view of health, toward services that recognize the influence of economic, social and environmental factors on health. Historically, EMS responds to existing illness or injury, but the reshaped EMS systems of the future will also promote health. An existing example of such reorientation of services that targets aging has been reported in Rochester, NY, where researchers have demonstrated that EMS providers can screen older adults during the course of an emergency response for their influenza immunization status.¹⁹ If such a role were adopted as routine practice, EMS would become an advocate for immunization, mediating between emergency services and traditional public health to enable the elderly to choose and obtain immunization.

        Importantly, these are not the only—or even the best—opportunities for EMS-based aging-related health promotion; these are examples. An actual health-promotion program would need to independently identify the most appropriate activities for that program based on local needs and resources. There might be clear opportunities for EMS-based health-promotion activities; there might also be opportunities for EMS to be a key multisectoral partner in broader health-promotion initiatives based in other areas. For example, EMS systems are cooperating with World Health Organization "Safe Communities" projects in several cities throughout the world. Health-promotion activities do not exist in a vacuum, and there is often significant overlap among individual initiatives, as well as the various strategies outlined by the Ottawa Charter. For example, a county health department initiative to build health capacity might include supporting policies that justify and support health promotion as part of the EMS system's mission, and thus facilitate reorienting of the health services provided by EMS. The opportunities are practically endless.

BARRIERS
     The barriers to any EMS-based health promotion activity are multifaceted. They are the barriers to health promotion generally,¹⁰ barriers to health promotion in a clinical environment,²⁰ difficulties associated with establishing new roles⁹ and the socio-political circumstances of today's world.²¹ They are the same challenges that nearly any discipline would face in the early stages of adopting health promotion into its mission. These barriers might be stated like:

     "We don't do that. This is EMS. We save lives."

     Behaviors and health habits are ingrained by both culture and attitude, and structures of healthcare (including EMS) and social support systems are equally well-ingrained. Change—changing behaviors, habits, systems, anything—is hard, particularly when the reward for that change may not be evident until many years later.¹⁰

     "I barely have enough time to put a heart failure patient on oxygen, start an IV and administer furosemide before we get to the hospital. When am I supposed to do health promotion?"

     In the clinical setting, and particularly in the emergency setting, attention and resources are necessarily focused on patient care. Clinicians (including paramedics) often lack the time, skills, materials, facilities or even the interest to conduct health-promotion activities.²⁰

     "Why are these EMS people out lobbying on behalf of the food stamp program? Clearly they have staff with too much free time. We need to reduce their payroll budget and save taxpayer dollars."

     Adopting a new role can be threatening for health providers; it challenges existing culture, requires acquisition of new skills, and raises questions about how performance might now be judged. On a systems level, new roles can further exacerbate existing issues with limited funding, particularly when policy-makers may not see the need for an expanded role.⁹

     "Clinic hours? We've got terrorists trying to blow up our country and you want to talk to me about the operating hours at the community clinic?"

     The world is getting smaller, life is getting faster, violence is increasing and uncertainty abounds. People (patients and paramedics, EMS system administrators and policy-makers) are scared and distracted. They have other pressing concerns.²¹

SolUTIONS
     The barriers to health promotion are ubiquitous and apply to EMS as they would to any other health discipline. Yes, it will be hard, but it's the right thing to do. Beyond that, some specific problem-solving strategies can be useful. Authors Ross Brownson, Debra Haire-Joshu and Douglas Luke²² listed 10 strategies for overcoming the difficulties associated with prevention of chronic disease that, with only minor revision, can be adapted for overcoming barriers to EMS-based health-promotion programs. Detailed explanations for and examples of each of these strategies are listed in Table II. These are certainly not the only strategies that might be successful. The literature is replete with descriptions of techniques for problem-solving and overcoming barriers; any of those approaches could likely be adapted for EMS-based health-promotion initiatives.

Table II: Sample Approaches for Overcoming Barriers to Health Promotion²²
     Start with environmental and policy interventions: Working to create healthy environments or healthy public policy avoids some of the difficulties associated with directly trying to change individual attitudes and behaviors or the structure of the EMS system, has less immediate impact on clinical caregiving, and may be less threatening than an initiative that requires explicit patient-oriented action by paramedics. It may be a safer place to start.

     Think comprehensively and across multiple levels: Health problems are multifaceted, and there is rarely one single intervention that can solve a health problem. Develop health-promotion initiatives that attack a problem on more than one front. They probably will not all be successful, but they might not all fail, either.

     Use economic evaluations: Money talks. Demonstrating the economic benefits of improved health, or at least the continued costs of poor health, can facilitate change at the individual (patients and paramedics), institutional (EMS and healthcare system) and governmental levels.

     Use existing tools: Adapt health-promotion initiatives and materials that have been successfully implemented in other areas and by other disciplines.

     Understand local context: Determine the kinds of EMS-based health-promotion initiatives the community (individuals, organizations, business, government) will be most receptive to and start with those.

     Understand politics: Identify key stakeholders in the community, and engage them in the efforts early. Be as inclusive as possible: Once invited, the health columnist for the local newspaper may decline to participate in an initiative; uninvited and scorned, the same columnist could torpedo the initiative.

     Build new and nontraditional partnerships: Pursue an intersectoral approach to every initiative and be creative. The sanitation department might have incredibly useful insights about how to address youth violence. (Garbage collectors see a lot of things the rest of us don't!)

     Address health: Keep the focus on improving health—holistic health—and participate in health-promoting initiatives that arise from other sectors. Support a Parks and Recreation request for funding for a new green space because it is good for health. Help the police crack down on speeding because it is important to pedestrian health.

     Learn from others: Keep abreast of what other EMS-based health-promotion programs are doing, the obstacles they're encountering, and the successes they're experiencing. Adopt things that have been shown to work elsewhere; don't waste resources on things that have already failed.

     Participate in research: Conduct ongoing evaluations of health-promotion efforts, and revise programs appropriately. Initiate, or at least participate in, scientific analyses of the results of health-promotion programs. Data supporting the effectiveness of EMS-based health promotion will help generate support for expanded and new programs.

CONCLUSION
     By joining forces with traditional public health, EMS can help to improve health for all people.⁹ Providing health education is one way EMS can contribute to the larger public health efforts,^2,8 but EMS-based health-education initiatives need to be founded in strong behavior-change theory.¹¹ Taking on the broader challenge of health promotion is another way that EMS can help improve societal health, and those health promotion efforts also need a strong theoretical foundation.¹² Taking on a new role is always difficult. New skills will have to be developed; obstacles will have to be overcome.^9,10,20,21

     Why should EMS participate in public health? Why not leave it to others? Because EMS itself will benefit from those health-promotion efforts. More important, because health is more than not being sick;⁵ the responsibilities of healthcare, including EMS, go beyond simply treating the sick;^3,6,7 EMS in its essence is more than healthcare;¹ EMS, more than any other discipline, sees firsthand the interdependence of health, economic security, social situations and environmental conditions;² and because EMS is uniquely positioned—perhaps better positioned than any other allied health discipline—to promote health. Because it's the right thing to do.

References

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3. World Health Organization: Declaration of Alma Ata. Geneva: World Health Organization, 1978.
4. World Health Organization: Ottawa Charter for Health Promotion. Geneva: World Health Organization, 1986.
5. Grad FP. The Preamble of the World Health Organization. Bulletin of the World Health Organization 80(12):981–984, 2002.
6. World Health Organization: The Jakarta Declaration on Leading Health Promotion into the 21st Century. Geneva: World Health Organization, 1997.
7. World Health Organization: Bangkok Charter for Health Promotion. Geneva: World Health Organization, 2005.
8. Garrison HG, Foltin GL, Becker LR, et al. The role of emergency medical services in primary injury prevention. Ann Emerg Med 30(1):84–91, 1997.
9. National Highway Traffic Safety Administration: EMS & public health: Building a partnership for community health care [electronic version]. Washington, DC: National Highway Traffic Safety Administration, 2000.
10. Bishop GD. On staying healthy. In Health Psychology: Integrating Mind and Body (pp. 68–91). Boston, MA: Allyn and Bacon, 1994.
11. D'Arcy C, Holmon J. Something old, something new: Perspectives on five 'new' public health movements. Health Promotion Journal of Australia 2(3):4–11, 1992.
12. O'Connor-Fleming ML, Parker E. Health Promotion Principles and Practices in the Australian Context. St. Leonards, NSW: Allen and Unwin, 2001.
13. Griffiths K. Best practices in injury prevention: National award highlights programs across the nation. J of Emerg Med Serv 27(8):60–74, 2002.
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15. Chapman S. Never say die? Medical Journal of Australia 183(11/12):622–624, 2005.
16. Clark MJ, FitzGerald G. older people's use of ambulance services: A population-based analysis. J Accident Emerg Med 16(2):108–111, 1999.
17. Clark MJ, Purdle J, FitzGerald GJ, et al. Predictors of demand for emergency prehospital care: An Australian study. Prehosp Dis Med 14(3):167–173, 1999.
18. Weiss SJ, Ernst AA, Miller P, Russell S. Repeat EMS transports among elderly emergency department patients. Prehosp Emerg Care 61(1):6–10, 2002.
19. Shah MN, Lerner EB, Chiumento S, Davis EA. An evaluation of paramedics' ability to screen older adults during emergency responses. Prehosp Emerg Care 8(3):298–303, 2004.
20. Bensberg M, Kennedy M, Bennetts S. Identifying the opportunities for health-promoting emergency departments. Acc Emerg Med 11:173–181, 2003.
21. Giles-Corti B, Wood L, Donovan R, et al. Opportunities and challenges for promoting health in a changing world. Health Promotion Journal of Australia 15(1):17–23, 2004.
22. Brownson RC, Haire-Joshu D, Luke DA. Shaping the context of health: A review of environmental and policy approaches in the prevention of chronic diseases. Annual Review of Public Health 27:17.1–17.30, 2005.

Lawrence Brown is currently serving as research associate professor and associate director of research for the Department of Emergency Medicine at the University of New Mexico Health Sciences Center in Albuquerque. In 2006, Lawrence moved to Queensland, Australia, to study at James Cook University, where he earned a Master of Public Health and Tropical Medicine. Since returning to the U.S., he has worked to strengthen the links between research, EMS and public health, specifically in resource-poor settings.

Sue Devine is a lecturer at the School of Public Health, Tropical Medicine and Rehabilitation Sciences at James Cook University in Townsville, Australia. She is trained in general nursing and midwifery and has completed a Master of Public Health and Tropical Medicine, a post-graduate diploma in Health Promotion and a graduate certificate in Tertiary Teaching. Sue has worked in health promotion and education roles throughout Queensland and Western Australia. She is currently working toward her Doctorate of Public Health.