Awareness of the impact of our lifestyle on health outcomes is increasing (Reiner et al, 2013; Dale et al, 2014; Wang and Geng, 2019). Lifestyle can be viewed as a collective term that covers various health behaviours. An unhealthy lifestyle may be characterised by a poor diet, physical inactivity, smoking, excessive alcohol intake, drug misuse, stress and so on; a healthy lifestyle is, in contrast, involving engagement in physical activity, maintaining a good diet and the absence of addiction and/or excessive stress (Farhud, 2015).
There is a consensus backed by an abundance of research that suggests that a healthy lifestyle has a positive effect on emotional and physical wellbeing (Biddle and Asare, 2011; Thorp et al, 2011; Walsh, 2011; Reiner et al, 2013; Dale et al, 2014; Wang and Geng, 2019). Health behaviours can impact all-cause mortality; in the United States, it has been reported that 40% of deaths can be attributed to poor health behaviours such as physical inactivity, poor diet and/or alcohol misuse (Pirrallo et al, 2005). Similar conclusions have been drawn in the UK; Kvaavik et al (2010) conducted a prospective cohort study to assess the role of lifestyle on mortality in 4886 individuals. Four poor health behaviours were assessed: cigarette smoking; excessive alcohol intake; physical inactivity; and low fruit and vegetable intake. Engagement in these behaviours was significantly associated with a higher risk of all-cause, cardiovascular disease and cancer mortality (Kvaavik et al, 2010).
Ambulance workers are repeatedly exposed to potentially traumatic events and suffering (Wild et al, 2016; Petrie et al, 2018). This exposure has been shown to heighten the risk of a stress reaction and the development of mental health issues including but not limited to symptoms of post-traumatic stress disorder (PTSD), anxiety and depression (Donnelly, 2012). Epidemiological evidence has estimated prevalence rates among ambulance workers of 11% for PTSD, 15% for depression, 15% for anxiety and 27% for general psychological distress (Petrie, 2018), compared with 15.7% of common mental disorders in the general population (McManus et al, 2016).
It is intuitive to suggest that a percentage of ambulance workers do not experience emotional difficulties and that not all exposure to trauma is negative (Paton et al, 2000; Jenner, 2007). A plethora of individual and lifestyle factors may moderate these effects, but the specific mechanisms by which they occur have not yet been fully explored nor defined in the literature; ambulance personnel are understudied (Kukowski et al, 2016).
Demand on the NHS in the UK is increasing and its resources are limited (National Audit Office (NAO), 2017; McCann et al, 2019). NHS ambulance trusts are having difficulties in recruiting and, more importantly, retaining employees (NAO, 2017). One of the most cited reasons for leaving the ambulance service is the stressful nature of the job (NAO, 2017). Research on work-related stressors and exposure to trauma widely accepts that the role of an ambulance worker is inherently stressful and may contribute to the onset of mental and physical health issues (Cydulka et al, 1997; Davis et al, 2019). While there is an abundance of awareness, support and intervention for an ambulance worker's response to emotional and physical stress (such as debriefing, trauma-focused therapy, trauma-informed approaches, physiotherapy, counselling and drug and alcohol screening), the provision of preventive interventions is limited (Donnelly, 2016). The World Health Organization (WHO) (2002) has identified however that wider concern should be targeted at implementing preventive interventions.
There is a growing evidence base to suggest that lifestyle factors may mitigate the onset and exacerbation of mental and physical health issues in the general population (Biddle and Asare, 2011; Thorp et al, 2011; Walsh, 2011; Reiner et al, 2013; Dale et al, 2014). Research shows that prevalence rates of mental health issues are higher in ambulance workers than in the general population (McManus et al, 2016; Petrie et al, 2018).
The authors therefore propose that there is a gap in the literature that needs to be addressed; evidence related to lifestyle, health and wellbeing outcomes in the ambulance worker population is scarce, and an understanding of the implications this may have on physical and mental health outcomes is limited. Because of the dearth of epidemiological data, there is a lack of evidence-based preventive interventions (Kukowski et al, 2016). The scope of this paper therefore is to review the existing evidence base on health behaviours in ambulance workers across the world and assess their applicability to the UK.
Method
Search strategy
Wellbeing is a broad term associated with positive psychological health (i.e. life satisfaction), diagnosed mental health issues (e.g. anxiety, depression and PTSD) and physical health (Petrie et al, 2018). Similarly, lifestyle is a broad term associated with both positive and negative behaviours, such as smoking, alcohol use, physical activity and diet, associated with a person's everyday functioning. Key search terms were formulated encompassing the spectrum of words associated with wellbeing and lifestyle.
Emergency services across the world have a structure or hierarchy of staff, who have varying levels of responsibility and remuneration to reflect this (Mahajan et al, 2019; Shakeri et al, 2019). Key search terms related to the target population were devised from the principal author's work-related experience and were reviewed by a second author.
A comprehensive search strategy was devised to identify relevant literature in searches of the following seven online bibliographic databases: MEDLINE, CINAHL, PsychArticles, PsychINFO, Web of Science, PubMed and Google Scholar (Table 1). To ensure relevance, inclusion and exclusion criteria were applied (Table 2).
| ((smok* OR ‘alcohol*’ OR ‘physical activity’ OR ‘exercise’ OR ‘trauma*’ OR ‘social support’ OR ‘support’ OR ‘risk factor’ OR ‘blood pressure’ OR ‘obesity’ OR ‘weight’) AND (anxiety OR ‘stress’ OR ‘depression’ OR ‘PTSD’ OR ‘post traumatic stress symptoms’ OR ‘PTSS’ OR ‘burnout’ OR ‘quality of life’ OR ‘suicidality’ OR ‘life satisfaction’) AND (paramedic* OR ‘emergency worker*’ OR ‘EMT’ OR ‘ambulance attendant’)) NOT (epithelial OR ‘mesenchymal’ OR “transmission’) |
| Inclusion criteria | Exclusion criteria |
|---|---|
| Any year of publication | Volunteer workers |
| Qualified emergency service workers and/or prehospital carers working in the ambulance service (paramedics, emergency medical technicians and emergency care assistants) | Other emergency personnel (nurses, doctors, firefighters and police) |
| Worldwide | Opinion articles |
| Empirical study | Qualitative methods |
| Quantitative methods using surveys, questionnaires or self-report measures | Focused on patient care or patient-related outcomes |
| Published in English (because of restriction of authors’ native language) | Reference to specific disasters or rescue workers (e.g. 9/11) |
| Measure of health behaviours (defined as smoking, alcohol use, sleep and physical activity/inactivity) | Papers written in a language that has not been translated into English |
| Full-text articles available | Reviews |
Data extraction
The principal author conducted the initial searches, filtering and reviewing, which started in October 2017 and concluded in November, 2019. The above mentioned online databases (MEDLINE, CINAHL, PsychArticles, PsychINFO, Web of Science, PubMed and Google Scholar) were searched. There were 2848 hits; duplicates were removed, which left 2721 results. Titles were screened, and a total of 29 papers were established to be relevant to the review based on inclusion and exclusion criteria (Table 2). Full abstracts were further screened for eligibility against these criteria.
The final papers (n=6) were read in full and hand-searched to identify additional relevant papers though none were eligible. Data were extracted from the final papers and a quality assessment was undertaken with the principle and second author. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed (Figure 1) (Moher et al, 2009).
Quality review
A quality review was conducted using Timmer et al's (2003) criteria: 18 quality indicators from their criteria were used and agreed by all authors. Each quality indicator was awarded as follows (unless otherwise specified) in line with Timmer et al's (2003) scoring: 2 points for full detail; 1 point for partial detail; and 0 points for insufficient or no detail.
These scoring criteria were applied to assess the following aspects of each article: description of objective; appropriate design (i.e. prospective cohort, retrospective cohort, cross-sectional, case control and case report/series, which scored, 4, 3, 3, 3 and 1 respectively), participant characteristics described, appropriate participant sample, control group, method of participant selection, outcome measures (validated self-report materials or objective measures), accountability, confounding variables, adequate sample size, appropriate reporting of statistical tests, reporting and analyses, attrition and results supporting conclusions. The total score that could be obtained was 28. The second author reviewed the papers and scoring was agreed with zero discrepancies. Quality scoring ranged from 18/28 to 23/28; both reviewers agreed that any score of 18–20 was adequate and >20 was good.
A descriptive analysis was undertaken of the final papers in the review (n=6). A meta-analysis was not feasible because of the variation in measurement outcomes between the studies.
It is worth noting that the papers included in this review each had different aims and objectives that are not necessarily consistent with the aims of the current review. It could be argued that the findings of the present study are somewhat serendipitous and reflective of the research field, as there is limited evidence on the health behaviours of those who work in the emergency services. Therefore, while ‘ambulance worker’ is the main term used to refer to the target population, there may be some variations, such as emergency medical technician (EMT) or emergency personnel.
Results
Characteristics of research
The papers included in this review (n=6) show a range of lifestyle factors that impact wellbeing outcomes of ambulance workers across the Western world (Pirrallo et al, 2005; Studnek et al, 2010; Betlehem et al, 2013; Hegg-Deloye et al, 2014; Kukowski et al, 2016; Wild et al, 2016). Table 3 displays their main characteristics.
| Author and location | Participant demographics | Measures | Outcomes |
Variables of relevance |
|---|---|---|---|---|
| Betlehem et al (2013) Hungary | n=364; recruited from the Hungarian National Ambulance Service | Literature-based questionnaire on self-perceived health status, defined as self-rated health, self-rated physical fitness, limitation of daily activities by health problems and chronic health problems | PH | Thirteen variables, five of which were relevant to this review and related to lifestyle: self-rated health, self-rated fitness, limitation in daily activities, leisure time and addictions |
| Hegg-Deloye et al (2014) Canada | n=295 paramedics, n=283 controls; recruited from any paramedic/ambulance staff living in province of Quebec; controls included office workers, university staff, self-employed people, marketers, sales people and research centre staff | 18-item, self-report questionnaire to collect data on age, height, body weight in the first year of employment, age, height, current body weight, tobacco use and current date; Pittsburgh Sleep Quality Index (PSQI); job content questionnaire and effort reward model; Three Factor Eating Questionnaire | PH | Nine variables, three of which related to lifestyle and are included in this review: body mass index (BMI), tobacco use and sleep |
| Kukowski et al (2016) Canada | n=87; recruited from Canadian metropolitan areas | Sleep measured by one tool from the PQSI; PTSD Checklist Civilian Version (PCL-C); Maslach Burnout Inventory | MH | Three relevant variables; sleep; post-traumatic stress disorder symptoms; and burnout |
| Pirrallo et al (2005) United States | n=1919; recruited from Health Behaviour Risk Survey | Health Behavioural Risk Survey (HBRS); |
PH | Four risk factor variables of interest: alcohol consumption, cigarette smoking, and moderate and vigorous physical activity |
| Studneck et al (2010) United States | n=30 560; recruited from national registry of emergency medical technicians | Used validated items from the Behavioural Risk Factor Surveillance System | PH | Seven variables, five of which were relevant to this review: existing heath conditions, general health, BMI, physical activity outside work and cigarette smoking patterns |
| Wild et al (2016) England | n=453 initially and n=386 in follow-up; recruited from the London Ambulance Service | Trained psychologists administered the Structured Clinical Interview for the DSM-IV; Life Events Checklist; subscale of Eysenck's personality questionnaire; anxiety sensitivity inventory; Connor-Davison resilience questionnaire; attitude to emotional expression questionnaire; depressive attributions questionnaire; PT cognitions inventory; responses to intrusions questionnaire; subscale from Coping Orientation to Problems Experienced (COPE) questionnaire; and crisis support scale. Completed at follow up: Alcohol Use Disorders Identification Test (AUDIT); self-reported days off work; self-reported weight changes; self-reported smoking status; insomnia severity index; and quality of life enjoyment and satisfaction questionnaire | PH and MH | Seventeen variables in total, four of which were relevant to this review: alcohol use, self-reported weight changes, self-reported smoking status and insomnia severity |
Body mass index
Of the six reviewed papers, three provided some insight into weight and ambulance workers (Hegg-Deloye et al, 2014; Studnek et al, 2010; Wild et al, 2016). The findings were consistent across all the reviewed papers.
Self-reported data on weight was converted into body mass index (BMI) by the researchers in two of the three papers (Studnek et al, 2010; Hegg-Deloye et al, 2014). Hegg-Deloye et al's (2014) retrospective study of 295 paramedics and Studnek et al's (2010) cross-sectional study of 30 560 registered EMTs showed a significant association (P<0.0001) between sex and BMI; men reported a higher BMI than women (Studnek et al, 2010; Hegg-Deloye et al, 2014). Hegg-Deloye et al (2014) included a control group and a significant interaction between time and occupation was established; paramedics were more likely to gain weight during the course of their employment than those in any other occupation.
With regards to associations between mental health and weight, Wild et al (2016) conducted a prospective cohort study with 453 newly recruited paramedics and found a relationship between weight gain and PTSD.
Physical activity
Three of the six papers explored physical activity (Pirrallo et al, 2005; Studnek et al, 2010; Betlehem et al, 2013). In two of the three studies, associations between sex and physical activity were explored, and findings in both studies were consistent (Pirrallo et al, 2005; Studnek et al, 2010).
In an attempt to represent physical activity objectively, Studnek et al (2010) used the Centre for Disease Control's (CDC) guidelines on physical activity to offset results of participants’ self-reported descriptions of their physical activity. Men were more likely than women to report meeting CDC recommendations. Similarly, in Pirrallo et al's (2005) cross-sectional study of 1919 EMTs, it was reported that women were less likely to participate in vigorous activity.
Betlehem et al (2013) was the most recent study to report on physical activity. The cross-sectional study of 364 participants, recruited from the Hungarian National Ambulance Service, established that those who participated in any type of sports or physical activity reported significantly better self-perceived health than those who did not (Betlehem et al, 2013).
Smoking
Four papers reported on cigarette or tobacco use. Two contributed to the research field from a demographic perspective (Pirrallo et al, 2005; Studnek et al, 2010) and the other two explored the impact of smoking (Hegg-Deloye et al, 2014; Wild et al, 2016). Self-report measures were used in all papers to capture participant data.
With regards to sex, female EMTs were significantly more likely to smoke than their male counterparts (P=0.0188) (Pirrallo et al, 2005).
Furthermore, ambulance workers who were meeting physical activity guidelines were less likely to smoke (Studnek, 2010). There was also evidence that those who self-reported as obese were less likely to smoke (Studnek, 2010).
The remaining papers conducted multivariate analysis to establish the impact of smoking on health (Hegg-Deloye et al, 2014; Wild et al, 2016). One paper indicated that tobacco use had a significant impact on BMI, where those who smoked fewer cigarettes had a lower chance of gaining weight (Hegg-Deloye et al, 2014). This contradicts Studnek et al's (2010) findings.
Relating to mental health outcomes, Wild et al (2016) reported that those who developed PTSD were more likely to smoke.
Sleep
Of the six papers, two assessed sleep in ambulance workers (Hegg-Deloye et al, 2014; Kukowski et al, 2016). Kukowski et al's (2016) cross-sectional study of 87 Canadian paramedics used three validated measures to assess sleep, post-traumatic stress symptoms (PTSS) and burnout. Regression models revealed that lower sleep quality was associated with PTSS when burnout was high in individuals (Kukowski et al, 2016); this showed that PTSS could play a damaging role in paramedic health in the sense of impact on sleep quality. Hegg-Deloye et al (2014) briefly reported that sleep quality had no significant effects on BMI.
Alcohol
Two papers explored alcohol use in ambulance personnel (Pirrallo et al, 2005; Wild et al, 2016). Pirrallo et al (2005) conducted a range of analyses on ‘risk-taking behaviours’, one of which was alcohol consumption. Comparisons were made between the career level of ambulance workers (basic level EMT or paramedic) and sex, against a control group (the US national estimates) (Pirrallo et al, 2005).
When comparing career level, basic-level EMTs were found to drink less than their paramedic counterparts; however, once demographic differences were controlled for in analysis, no differences were reported.
Significant differences were found between the sexes, with male EMTs likely to drink more alcohol than their female counterparts (P<0.0001). When compared with US national estimates, alcohol consumption was not lower than, nor did it exceed, that of similar adults in the control group (Pirrallo et al, 2005). Alcohol consumption was assessed by validated questionnaire in Wild et al's (2016) study, which used the Alcohol Use Disorders Identification Test (AUDIT) (Babor et al, 2001). A significant reduction in the AUDIT score was reported at the 2-year follow-up in paramedics.
Discussion
To meet the aim of this paper, ambulance workers’ engagement in various health behaviours were reviewed and the findings presented here illustrate the associations and impact of these on emotional and physical wellbeing.
Overall, ambulance workers are more likely to gain weight throughout their employment, physical activity differs between sexes, smoking has a negative impact on emotional and physical health and that alcohol intake was no higher in this occupational group than in the general population. The significance of individual lifestyle choices and engagement in certain behaviours is important within the ambulance services because of their exposure to emotionally demanding and physically strenuous activities (Petrie et al, 2018).
Men reported higher BMI (Studnek et al, 2010; Hegg-Deloye et al, 2014); this is in conflict with epidemiological data for the general population which suggest that obesity is higher among women (Arroyo-Johnson and Mincey, 2016). Further evidence suggests that increasing BMI may be problematic for ambulance workers (Hegg-Deloye et al, 2014). These findings indicate that occupation-specific factors may impact the lifestyle and consequently the BMI of this population, so weight is a variable that could be monitored in ambulance workers as it is a contributing factor to all-cause mortality. This mirrors the finding by Studnek et al (2010) that people who were obese were more likely to report having health conditions.
Arguably, one of the biggest influencers of weight gain is physical inactivity or a sedentary lifestyle; physical activity is associated with weight loss (Thorp et al, 2011). The findings in this review were consistent with this idea; physical activity improves self-reported health (Betlehem et al, 2013). The papers in this review reported evidence that male ambulance workers were more likely to engage in physical activity (Pirrallo et al, 2005; Studnek et al, 2010). Given the current evidence base, which suggests that physical activity ameliorates weight gain, it could be argued that this finding negates the earlier point that men are more likely to be obese (Hegg-Deloye et al, 2014). However, the authors were unable to establish a control for the level of exercise and there is evidence to suggest that physical activity is lower among ambulance workers in general, which would explain the aforementioned finding related to BMI (Barrett, 2016).
Furthermore, there is increasing recognition that BMI and weight are complex variables with many influencing factors beyond physical activity alone (Wang and Geng, 2019). To illustrate, research outside this review has explored the role of social cognitive theory (Bandura, 2011) in physical activity, which found that self-efficacy and self-regulation play important roles in physical activity participation (Mailey et al, 2016). Prioritisation and planning are key to improving self-efficacy and self-regulation (Mailey et al, 2016). However, there may be external factors acting as barriers to physical activity, such as time and financial constraints (Betlehem et al, 2013).
It could be inferred that, for this occupational group, self-efficacy and self-regulation may be difficult to establish and maintain owing to organisational stressors such as shift work and overtime, which may conflict with personal/family commitments, potentially depleting internal resources.
As with physical inactivity, it is generally accepted that smoking is a maladaptive health behaviour (Pirrallo et al, 2005). Overall, the consensus in this review is that smoking was associated with poorer mental and physical health outcomes in this population (Pirrallo et al, 2005; Studnek et al, 2010; Hegg-Deloye et al, 2014; Wild et al, 2016). In the context of this review, the authors were unable to establish whether this was occupation-specific; however, given the abundance of research that suggests the negative impacts of smoking, the finding itself is not surprising.
In addition, it is noteworthy that smoking prevalence is high in populations with mental health issues (Burki, 2016). It may therefore be inferred, because of the higher prevalence of mental health issues in ambulance workers, that smoking may be higher within this occupation. This was also reported in Wild et al's (2016) study, but the correlations between smoking and PTSD should be taken with caution as causality cannot be assumed.
While the findings in this review are somewhat supportive of the notions in existing research, the diversity of the ways in which smoking was assessed in the reviewed studies makes it difficult to draw firm conclusions and it would not be identified whether smoking was an occupation-specific behaviour. Nevertheless, it is important to focus and tailor interventions, as suggested by Taylor et al (2014), whose systematic review reported that smoking cessation was associated with reductions in depression, anxiety and stress.
Similarly, evidence varied regarding the impact of sleep on psychological and physical wellbeing. Although it is widely accepted that sleep deprivation has a negative impact on emotional and physical wellbeing and functioning (Orzeł-Gryglewska, 2010), the findings in this review were not conclusive; this could be attributable to the fact that the papers were assessing the impact of sleep on different variables (PTSS and BMI). Given that shift work is a frequently cited occupational stressor for ambulance workers, it is surprising that assessment of the variable in this study yielded inconclusive findings; again, this is likely to be explained by limitations of this review with the inclusion and exclusion criteria specified.
The review identifies that alcohol use was not a problematic health behaviour per se; alcohol use in this occupation group was not found to be any higher than in the general population. Furthermore, in one prospective study, levels of alcohol consumption were lower than average (Wild et al, 2016). However, that is not to say that the level of consumption in the general population was in line with recommendations.
Limitations
This review is restricted in terms of being able to draw firm conclusions because of the limitations of the studies included (Table 4). The papers were limited to research based in Westernised countries. Emergency services operate worldwide, providing a varying quality of service and this limitation has implications for the external validity of the findings.
| Limitation | Studies |
|---|---|
| Reliance of self-reported data, which raises risks of response set bias and social desirability (Field, 2013), which is reportedly more pronounced in recalling negative health behaviours (Perry et al, 1995) | Betlehem et al (2013); Hegg-Deloye et al (2014) |
| Body mass index (BMI) was used as a health indicator in the reviewed studies, calculated from self-reported height and weight. However, there are caveats regarding BMI as a measure (Connor Gorber et al, 2007). A systematic review of 64 studies that measured BMI and self-reported height and weight established that, overall, data trends illustrate under-reporting of weight and over-reporting of height. Given these are the two variables used to calculate BMI, the utility of BMI as a reliable measure is open to criticism (Gorber et al, 2007) | Studnek et al (2010); Hegg-Deloye et al (2014); Wild et al (2016) |
| Self-report on physical activity was frequently measured by closed questions and variables often dichotomised (e.g. ‘yes/no’), which fails to account for individual differences and findings may not be representative. The notion of being physically active differs between individuals and the question ‘are you physically active?’ is not straightforward. A person may not regard themselves as physically active because of societal biases on how this may be defined | Pirrallo et al (2005); Studnek et al (2010); Hegg-Deloye et al (2014) |
| A range of methods were used to collect the self-reported data in the reviewed studies; online, telephone, recertification registers and self-report with monitoring, each of which has its own limitations because of reliance on participants’ accuracy, interpretation and self-awareness | Pirrallo et al (2005); Studnek et al (2010); Hegg-Deloye et al (2014); Wild et al (2016) |
| Although the sample of studies included in this review are primarily from western countries, to apply this to a specific nation's ambulance service is naive in approach. There is diversity not only within countries and communities but also within services (Mahajan et al, 2019; Shakeri et al, 2019) | Pirrallo et al (2005); Studnek et al, (2010); Betlehem et al (2013); Hegg-Deloye et al (2014); Kukowski et al (2016); Wild et al (2016) |
Additionally, the small number of reviewed papers limits the reliability of the data and prevents the possibility of conducting of a meta-analysis to draw clearer conclusions about the impact or role of lifestyle on ambulance workers’ wellbeing. However, this is reflective of the research field, which in itself is sparse and understudied (Kukowski et al, 2016).
Future research
Recommendations for future research and practice were raised in the papers reviewed. It has been reported that there is no single way to ameliorate the impacts of emotional and physically demanding working (Betlehem et al, 2013).
Although findings appeared not to be occupation-specific, there is a general consensus among the reviewed papers that preventive interventions specific to this occupational group should be offered (Pirrallo et al, 2005; Studnek et al, 2010; Betlehem et al, 2013; Hegg-Deloye et al, 2014; Kukowski et al, 2016; Wild et al, 2016). A range of interventions were suggested: lifestyle interventions (Betlehem et al, 2013), interventions to prevent maladaptive eating behaviours at work (Hegg-Deloye et al, 2014), interventions that foster a sense of personal accomplishment to improve sleep quality and overall health (Kukowksi et al, 2016), behavioural risk reduction programmes (Pirrallo et al, 2005), resilience-focused interventions (Wild et al, 2016) and interventions to improve diet and increase physical activity, including recommendations of an on-the-job fitness centre and monetary incentives (Hegg-Deloye et al, 2014).
Based on this review, several lines of enquiry for future research are warranted before any intervention is developed to support ambulance workers’ wellbeing. Given that evidence from this review is limited, future researchers and practitioners may wish to: further explore health behaviours and lifestyle in ambulance workers through use of validated measures related to lifestyle factors; and/or assess and examine the role and impact of health behaviours and lifestyle in ambulance workers.
From a methodological perspective, while questionnaires as a means of data collection are time-efficient and can collect useful epidemiological data, surveys are not necessarily the best method to capture the complexities of behaviours (Field, 2013). In the future, mixed methods, including the use of objective measures, could be used to capture and address the complexities and barriers to constructive health behaviours.
Finally, should interventions be tailored to this occupation, inter- and intra-national, cultural and organisational differences should be considered when applying such interventions.
Conclusion
This review provides a summary of health behaviours in the ambulance worker population in the Western world in line with PRISMA guidelines. It can be seen from the review that ambulance workers engage with both positive and negative health behaviours (i.e. physical activity, smoking and alcohol intake) and the impact of this on emotional and physical wellbeing varies.
Further research is warranted as to assess where there are differences between the general population and ambulance workers; findings could provide further rationale for developing and providing a dedicated, evidence-based, occupation-specific intervention.