Exploring the Impact of the Ecological Model of Health on Community Paramedicine: A Multilevel Perspective
- Feb 16, 2024
- 6 min read
Updated: Mar 26, 2024
As a paramedic, we are often faced with patient populations that have adversity to health care access (be it socioeconomic status, housing disparities, race, gender, or even smoking). This exposure makes knowledge about multilevel approaches to health important to patient outcomes. In this blog, I seek to explore the use of the Ecological Model of Health (a multilevel approach) in the setting of Community Paramedicine.
MULTILEVEL APPROACHES TO HEALTHCARE
Multilevel approaches to healthcare seek to create solutions where exposures at various levels of organization can work together to create positive health outcomes (Galea, 2015).
Galea states, “multilevel perspectives do not simply ‘add’ isolated ‘risk factors’ at other levels of influence to our prediction models. Multilevel frameworks should allow us to examine the interface between levels and quantify interactions across levels” (2015, para. 6). She explains that exposures are positioned upstream and downstream of individual factors and determinants of health (Image 1). Considering this, one who moves farther upstream has a higher incidence of exposure and is more at risk of adverse physiological health outcomes, according to this theory. All of this leads the author to explore how social behaviours produce health behaviours that in turn may result in pathophysiological manifestations of disease (Galea, 2015).
THE ECOLOGICAL MODEL OF HEALTH
The Ecological Model of Health is a multilevel approach important to understand and apply to paramedicine. Specifically, it can have beneficial applications in the new area of Community Paramedicine (CP). The Ecological Model of Health “emphasizes
environmental and policy contexts of behaviour while incorporating social and psychological influences (Glanz, Ch. 20)” At its core, it seeks to explain that
behaviour has many levels of influence that include individual (biological, psychological), interpersonal (social), organizational, community, the physical environment, and policy (Glanz, Ch. 20). Understanding these levels of influence can be used by health care practitioners to help educate and promote change (National Institute of Heath, 2005). There is an interaction between the various levels of influence and altering one can alter other levels of influence. One example that is used widely in literature is smoking cessation. By starting at an individual level, we can offer education to the public about the dangers of smoking which can in turn change their physical environment, beliefs, and their overall physical health (National Institute of Heath, 2005).
The individual level of influence is the fundamental level that all others are built on. Moving upstream from the individual level, we must consider interpersonal or social health barriers. “Assume individuals exist within and are influenced by a social environment. The opinions, thoughts, behaviour, advice, and support of the people surrounding the individual influence his/her feelings and behaviour” and vice versa (National Institute of Heath, 2005, pg. 19). As the adage says, “birds of a feather, flock together”. Educating and bringing new resources into a group can help overcome collective ideas that will in turn help change overall population health.
Comprehensive health promotion programs advocate for education and other techniques to help support individual behaviour change within an organization and regulatory change. This is a change we see at the community level. The community level is important because it shows us how social systems function and change and how to mobilize community members and organizations (National Institute of Heath, 2005). Community levels will address groups, institutions, communal beliefs and can be geographical or involving collective identities (National Institute of Heath, 2005).
COMMUNITY PARAMEDICINE
All of this is important to the application of CP. CP is an innovative branch of traditional paramedicine that offers care outside of typical paramedic roles (Agarwal, 2018). “[CP] is associated with improved health outcomes, reductions in healthcare spending, and reduced ED use (Allana & Pinto, 2021, pg. 69).” Many studies have shown that expanding the roles of paramedics to include health promotion and referral to appropriate service providers can be successful (Agarwal, 2015). In other areas where CP has been implemented, expanded
roles have included community education, preventative services, the actual treatment of minor illnesses in the community (rather than an acute or urgent care center), health lifestyle promotion, and management of chronic diseases (Agarwal, 2015).
In Ontario, various paramedic services are involved in a pilot program called Community Paramedicine at Clinic (CP@Clinic) - a community-based health promotion and disease prevention program for seniors residing in subsidized housing (Agarwal, 2018). CP@Clinic paired with Hamilton Paramedic Service (HPS) to create a multilevel approach to target issues experienced by seniors that typically result in paramedic calls (Agarwal, 2015). This multilevel approach includes “a health risk assessment (cardiovascular disease, diabetes, falls), health education and promotion, appropriate referral and feedback to [GPs] (Agarwal, 2015, pg. 2).” This program has built on existing community resources such as “local wellness programmes, referrals to Community Care Access Centers (CCAC), and staffing ... paramedics ... trained in health promotion (Agarwal, 2015, pg. 2).”
Initial studies showed a 25% reduction in 911 calls (Agarwal, 2018) as well a qualitative improvement in overall wellbeing (based on developed scoring measures) (Agarwal, 2018). The demographics in this trial are exposed to many adversities at individual, interpersonal, and community levels. From lack of education and understanding surrounding chronic conditions or lifestyle risk factors, to changing collective outlooks and to a low socio-economic status affecting overall access to education and care (to name a few).
Allana & Pinto (2021) identified that paramedics have an untapped potential at bridging the gap and improving overall personal health outcomes for various populations stating, “... many emergency calls are non-urgent, exacerbated by social factors, and related to gaps in primary care.” They goes on to explain that “...these newer models suggest paramedics are capable of addressing ... [these] factors when appropriately educated and supported (Allana & Pinto, 2021, pg. 69).”
CP @ Each Level of The Ecological Model of Health
There has been clear evidence of changes to our vulnerable populations under the CP programs, but how specifically does each level of the Ecological Model of Health influence its success. Below is a brief exploration of the application of each level to CP
Individual - CP works to empower older adults to educate themselves and become more responsible for their own health outcomes, work with individuals to set health goals (Home, 2024)
Interpersonal - Increased personal development and education creates overall improvement by positive conversations between peers
Organizational - assisting in connecting to primary care, helping to navigate the health care system (Home, 2024)
Community - Increased individual education improved overall group attitudes toward health
Physical Environment - helping patients with organization of their house, medications, and navigation around homes for individuals with mobility issues
Policy - Reduced 911 calls, implementation of clinics at low income/marginalized populations to increase visibility of care. Cost effective, for every $1 spent at clinics, emergency care sees $2 in benefits, this is further explained in the video below (Home, 2024)
(Home, 2024)
With the implementation of CP across paramedic services in Ontario, it is important for paramedics to have a greater understanding of multilevel approaches to health. Community paramedicine has built a foundation on addressing poor population health from a multilevel approach to improve personal and population health for patients. Paramedics who are working on the road should be well versed and given additional tools to help assess for and find solutions to various levels of influence when faced with them in the community. Using the Ecological Model of Health is imperative for paramedics to understand the interaction between individual, interpersonal and community factors affecting health. This could help improve our community’s individual health, population health, and promote better implementation of our community paramedicine programs at the service level.
(Region of Waterloo, 2022)
RESOURCES
Agarwal, G., McDonough, B., Angeles, R., Pirrie, M., Marzanek, F., McLeod, B., & Dolovich, L. (2015). Rationale and methods of a multicentre randomised controlled trial of the effectiveness of a community health assessment programme with Emergency Medical Services (CHAP-ems) implemented on residents aged 55 years and older in subsidised seniors’ housing buildings in Ontario, Canada. BMJ Open, 5(6). https://doi.org/10.1136/bmjopen-2015-008110
Agarwal, Gina, Angeles, R., Pirrie, M., McLeod, B., Marzanek, F., Parascandalo, J., & Thabane, L. (2018). Evaluation of a Community Paramedicine Health Promotion and Lifestyle Risk Assessment Program for older adults who live in social housing: A cluster randomized trial. Canadian Medical Association Journal, 190(21). https://doi.org/10.1503/cmaj.170740
Allana, A., & Pinto, A. (2021). Paramedics have untapped potential to address social determinants of health in Canada. Healthcare Policy | Politiques de Santé, 16(3), 67–75. https://doi.org/10.12927/hcpol.2021.26432
Galea, S. (2015, May 31). The determination of health across the life course and across levels of influence. SPH The Determination of Health Across the Life Course and Across Levels of Influence Comments. https://www.bu.edu/sph/news/articles/2015/the-determination-of-health-across-the-life-course-and-across-levels-of-influence-2/
Glanz, K., Rimer, B. K., & Viswanath, K. (2008). Health Behaviour and Health Education: Theory, research and Practice /Karen Glanz, Barbara K. Rimer and K. Viswanath, editors (4th ed.). John Wiley.
Home. CP@Clinic. (2021, June 24). https://cpatclinic.ca/
National Institutes of Health, Rimmer, B. K., & Glanz, K., Theory at a Glance: A guide for health promotion practice (2005). National Cancer Institute. Retrieved February 15, 2024, from https://www.sbccimplementationkits.org/demandrmnch/wp-content/uploads/2014/02/Theory-at-a-Glance-A-Guide-For-Health-Promotion-Practice.pdf.
Region of Waterloo. (2022, February 1). Council’s Corner: Community Paramedicine Program. YouTube. https://youtu.be/iHuaMdIF91E?si=F-UWXmikgLo42Lp_
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