Research has consistently shown that the physical health of people with mental illness is poorer than that of the general population, and that this area is often neglected by health professionals (Collins et al, 2013). A variety of factors have been found to increase the risk of this group experiencing serious illness and premature death, many of which are out of the individual's control (Mutsatsa, 2015). Nash (2014) suggests that physical health is now considered an integral part of modern mental healthcare—embracing a holistic model incorporating mental, physical, emotional and social components—and this is reflected by the recent government drive to improve this area of mental healthcare (Department of Health and Social Care (DHSC), 2016).
One in four people in the UK will experience a mental health problem at some time (NHS England, 2018), so mental ill health affects a significant proportion of a paramedic's patients. Paramedics could use their contact with these patients as an opportunity to assess and promote their physical health’ (Public Health England, 2017).
The prehospital acute setting of the paramedic has its own, unique challenges, particularly in terms of limited contact time with the patient (Gregory and Ward, 2010), while also being recognised as a common interaction point for people with mental illness in the community (Jack and Jadzinski, 2017).
Factors contributing to poor physical health
The World Health Organization (WHO) (2018) identifies three broad areas that influence health:
Individual factors that can significantly affect a person's health are diet, exercise, smoking, drug and alcohol misuse, and unsafe sexual practices (Nash, 2014).
These are often viewed and termed ‘lifestyle choices’ in literature, which implies that the individual is aware of the risks and impact on their health (Upton and Thirlaway, 2014). Recent research analysis confirms the importance of these factors and how they are linked to physical and mental health (Ohrnberger et al, 2017), and continues to use the terminology of lifestyle choices.
This idea of choice is being challenged. Robson (2013) suggests that these are not necessarily choices at all, but can be a direct result of the physical, social and psychological effects and associated treatment for a patient's mental illness. Collins et al (2013) support this view and add that applying the same level of responsibility for these behaviours is not always appropriate for people with mental health problems, and this should be considered when supporting individuals to make changes.
The impact of these behaviours on physical health is undoubted, particularly in relation to cardiovascular and respiratory illness, metabolic disorders and cancer (Nash, 2014).
Mutsatsa (2015) also highlights that medication for mental health conditions can be a significant factor in people's physical health, particularly the link between psychotropic medication and weight gain, and the health problems associated with obesity, such as cardiovascular disease and diabetes.
Diagnostic overshadowing and stigma
Wider factors that can influence an individual's physical health include substandard and disjointed care, stigma preventing the individual seeking help, and diagnostic overshadowing (Collins et al, 2013). While much has been written to highlight these issues, McGuinness and Follan (2016) suggest that it appears these barriers to improved physical health persist and need addressing.
Nash (2014) describes diagnostic overshadowing as being where a clinician dismisses a patient's physical complaints as part of their mental illness. This view is supported by Mutsatsa (2015), who highlights the lack of physical tests carried out on these patients despite the increased physical health risk factors associated with mental illness. Stigma can make patients reluctant to highlight physical complaints because they are unwilling to communicate with clinicians; have difficulties in articulating their concerns; or have experience of not being taken seriously (Collins et al, 2013).
Conspicuous by their absence are discussions and acknowledgement of diagnostic overshadowing in key paramedic literature (Gregory and Ward, 2010; Blaber, 2012; Nixon, 2013; Willis and Dalrymple, 2015). The extent of the problem in mental health and other nursing environments (Mutsatsa, 2015; Woodward, 2017) suggests that all practitioners are at risk of diagnostic overshadowing. Shefer et al (2014) agree, suggesting that this is an area requiring more consideration in emergency care, where regular attendees are especially vulnerable to not having their physical needs being taken seriously enough. Diagnostic overshadowing can also be compounded by a clinician's misconception that a patient with mental illness is not interested in their physical health (Mutsatsa, 2015).
Paramedics promoting health
Promoting improved physical health is multifaceted. Lifestyle behaviours, socioeconomic factors and inequality, as well as medical intervention and treatment, combine to influence a patient's health (Blaber, 2012; Ohrnberger et al, 2017). The paramedic's role in promoting physical health is starting to receive more attention, with the College of Paramedics (2015) including it as part of the scope of practice, and ambulance services acknowledging the importance of using contact time with patients for this purpose (Association of Ambulance Chief Executives (AACE), 2017).
While research on the effectiveness of health promotion by paramedics is limited, the opportunity to positively influence and promote improved health has been suggested (Smart, 2009; Donohoe et al, 2012). The promotion of physical health for people with mental illness is vital, although it comes with challenges and barriers (Collins et al, 2013). The debate over what is effective in health promotion is ongoing, with different theories and approaches being put forward (Corcoran, 2013). Cragg et al (2013) agree, pointing out that theories cannot be applied rigidly to all problems in all situations, but rather must be refined and adapted to the particular issue and set of circumstances.
Making every contact count
There are a number of health promotion models, including the Health Belief Model, the Self-Efficacy Theory and the Self-Regulation Model (Mutsatsa, 2015). NHS England's (2016) Making Every Contact Count (MECC) approach is relevant and practical to the singular encounters paramedics have with patients. MECC embraces a behaviour change model that uses the brief interpersonal encounters clinicians have with patients to increase their knowledge and motivate them towards making positive changes (NHS England, 2016). It is based on Prochaska and DiClemente's Stages of Change Model, which acknowledges the complexity of change and the various stages of this and problems encountered (Percival, 2014). MECC empowers and supports individuals to make informed lifestyle changes to damaging behaviours such as alcohol and substance misuse (Naidoo and Willis, 2016).
Although there is some concern over the quality of the evidence base (McCambridge, 2013), brief interventions have been shown to be useful and cost effective (National Institute for Health and Care Excellence (NICE), 2014; Angus et al, 2017). Upton and Thirlaway (2014) suggest multiple brief interventions are more effective than single brief encounters, but raise concerns over their lack of long-term impact. The author acknowledges this; the practicalities of single, limited contact time constrain what paramedics can implement in terms of detailed and repeated intervention and promotion.
While interpersonal, one-to-one communication is at the bottom of the communication hierarchy for the number of people it can reach, research suggests it is effective when combined with community or organisational health promotion (Corcoran, 2013). Norman and Ryrie (2013) agree, highlighting the importance of collaboration between primary and secondary care to achieve positive changes. Mutsatsa (2015) highlights that empowerment is central to promoting physical wellbeing; this helps combat feelings of loss of control and helplessness prevalent in mental illness, particularly in long-term interactions with mental health services.
Norman and Ryrie (2013) identify that information giving can be a useful starting point, and the credibility of the person delivering the message is critical. Paramedics are generally well regarded and can use this to credibly communicate positive health promotion (Blaber, 2012). Butler (2016) suggests that brief interventions can be used to de-stigmatise mental health problems.
Mutsatsa (2015) highlights the importance of the individual's own view of their health; if they believe they are physically well or are apathetic towards increased risk from damaging behaviours, any health promotion must take this into account. Naidoo and Willis (2016) point out that the individual must bring about the change for it to be effective, and people who already have problems in their lives will find this harder.
Practitioners benefit from understanding which stage of change individuals are at when discussing behavioural changes with them. These stages are: pre-contemplation; contemplation; preparation; action; or maintenance (Gottwald and Goodman-Brown, 2012). To be successful, the discussion should be tailored to the individual; they should not be pressurised, and information should be given that allows self-efficacy and starts to instil the belief that change is possible (Mutsatsa, 2015).
Changing culture
Paramedics have the opportunity to support positive behavioural changes through MECC, and acknowledge the importance of the physical health of a patient with mental illness.
A key starting point is dealing with diagnostic overshadowing: without an awareness of a patient's physical health needs, there can logically be no support or useful targeted health promotion. Paramedics can deeply affect a patient's view of healthcare and whether to seek assistance. It is within the paramedic's control to identify and alter negative behaviours in themselves and improve the patient's view of emergency and primary care (Blaber, 2012). Paramedics must be conscious not to label people as ‘mental health patients’ and thereby disregard their physical health; instead, they should adopt a holistic approach to healthcare (Willis and Dalrymple, 2015).
By being more aware of their own mindset and behaviour in relation to stigma and diagnostic overshadowing, paramedics can support a general change in culture within the emergency environment towards patients with mental health problems (Shefer et al, 2014). Mental health stigma is powerful, and clinicians perpetuating stereotypes will reinforce and deepen an individual's isolation; practitioners should challenge these perceptions through positive interactions (Rogers and Pilgrim, 2014).
In cases of self-harm, paramedics have a privileged opportunity to see the home circumstances to gain a fuller understanding, which hospital staff will not have (NICE, 2004). Collins et al (2013) suggest an inclusive approach for treatment, with self-care advice as part of an overall therapeutic relationship. Clinicians must be mindful of their own behaviour and approach when dealing with patients who have self-harmed. Butler (2016) suggests that clinicians, especially when tired and feeling frustrated with a patient, should remember that self-harm is a manifestation of distress that the patient has found no other ways of expressing; practitioners should adopt an empathic and patient-centred approach at all times (Nixon, 2013). Butler (2016) reminds us to consider our own previous poor choices when dealing with patients who have harmed themselves.
Regular monitoring of patients at increased risk of physical health due to mental health conditions is crucial (McGuinness and Follan, 2016). To support this regular monitoring, paramedics can use the brief opportunities to assess a patient's health status, which can encourage them to attend other health appointments that are outside of the paramedic's remit, embracing the MECC strategy (NHS England, 2016). Paramedics can tailor a health promotion discussion to the individual, ensuring it is relevant and meaningful to them (Corcoran, 2013).
By being more aware of national and local campaigns, as well as local support groups and organisations, paramedics can align health promotion to empower and support patients in the most effective way (Gottwald and Goodman-Brown, 2012). Making the most of the brief intervention in supporting behaviour change in relation to alcohol and substance misuse ensures a consistent message across the patient's interaction with all health professionals; this is of particular importance with the additional challenges posed by dual diagnosis (Hill et al, 2016).
Conclusion
It is important to consider the physical aspect of a patient with mental illness as part of a holistic approach to care (Nash, 2014). Individual circumstances and wider influences can be compounded to affect a patient's physical health; an awareness of these issues, along with an understanding of the complexities around supporting behavioural change are all required by the clinician (Collins et al, 2013).
The paramedic profession must begin to acknowledge and appreciate the issues around diagnostic overshadowing and stigma, with open discussion and self-awareness being the catalysts to changing the culture and attitude towards patients with mental illness (Shefer et al, 2014).
Health promotion is in its infancy for the paramedic profession, and paramedics could learn from the experiences of other professions to ensure the most effective approach is adopted. Nursing experience has shown that specific training in MECC as an NHS strategy could benefit all clinicians and support them in using it effectively (Percival, 2014).
Given the benefits, MECC is something the paramedic profession should adopt more proactively and widely. Recognising the importance of physical health in mental healthcare is essential to ensure the profession is providing the highest standard of care to one of its most vulnerable patient groups.