Authors: Jason Williams, Vincent Ramsey
Corresponding Author:
Jason J. Williams MSBM
1 Academy Drive
Daphne, Alabama 36526
251-626-3303 x7151
jjwilliams@ussa.edu
Contributing Author:
Vincent K. Ramsey, Ph.D.
1 Academy Drive
Daphne, Alabama 36526
251-626-3303 x7154
vramsey@ussa.edu
Jason Williams is a Doctoral Teaching Assistant at the United States Sports Academy. His research interests include strength and conditioning for special populations, linear speed, and power development.
Dr. Vincent Ramsey is Chair of Sports Exercise Science at the United States Sports Academy. Prior to his employment to the Academy, Dr. Ramsey spent 10 years as a lecturer at the University of North Georgia for the Department of Health and Physical Education and Recreation.
ABSTRACT
Police work is a paradox between two contrasting realities. One reality encompasses a sedentary environment comprised of long periods of sitting and inactivity. However, the other encompasses life and death situations often necessitating maximum intensity physical exertion. This unique environment along with other factors contribute to alarming health consequences including, but not limited to obesity, diabetes, cardiovascular disease, metabolic syndrome, hypertension, alcohol and drug abuse, as well as mental health issues. Intervention programs involving physical fitness, nutrition counseling, general wellness, stress management, and drug and alcohol education have shown promise with combatting the health maladies common to law enforcement. This review explores some of those successes and offers recommendations for high level decision makers capable of instituting transformational change. Although a more holistic approach to wellness is optimal, the primary focus is of this review is given to strength and conditioning intervention. Police are the lifeblood of law and order, vital to the health of communities. Creating holistic and practical wellness programs that meet the needs of law enforcement agents is a social responsibility and critical for this essential member of society.
Keywords: Police, Law Enforcement, Speed and Agility, Agencies, Cardiovascular, Power
INTRODUCTION
Law enforcement personnel (LEP) play a vital role in local communities, namely maintaining law and order. Thus, investing in the health and wellness of a community’s greatest asset is both responsible and necessary. A scarcity of research exists concerning widespread health and wellness interventions specifically targeted at law enforcement personnel. Intervention programs examined in this review will be defined as either internal intervention or external intervention. An illustration of internal intervention would be hiring a full-time employee to oversee department health initiatives. Conversely, an illustration of external intervention would be outsourcing training to qualified professionals who oversee health initiatives.
The purpose of this review is to discuss the need for specific health and wellness intervention programs in law enforcement populations and determine why they are necessary. For brevity, special emphasis is given to strength and conditioning but in no way does this focus reduce the importance of other intervention variables such as stress management techniques, and addiction counseling. Furthermore, essential components of an appropriate police officer program will be recommended with a specific emphasis on combat preparation and producing healthier LEP through long-term strength and conditioning programming.
Health Status of LEP
Police work has been found to be 80-90% sedentary (1, 4, 9, 10). An average day consists of long periods of sitting (23) and unexpected periods of maximal exertion (10). It is not uncommon for LEP to experience large increases in body weight as length of time on the force increases (9, 10, 15, 43, 61, 63). A study reviewing 41 different occupations revealed that police officers and firefighters have the two highest obesity rates (15). Ramey et al. (64) studied Milwaukee police personnel and found a higher rate of obesity among officers when compared to the general population. Yet, another study found that 33.6% of all North American police officers are obese (63). Moreover, officers who work 8 to 10-hour night shifts have even worse obesity percentages compared to police officers who do not work night shifts (14). Similar findings exist in other work populations (16).
Scholars studying officers in Buffalo, NY between 1950 and 1979 indicated substantially higher mortality rates for cancer, arteriosclerotic heart disease, and suicide for officers when compared to the US white male population (93). The researchers found lifestyle factors such as eating habits, stress, irregular sleeping habits, lack of exercise, and drug and alcohol use as primary causes (93). Other studies indicate high levels of hypertension and cardiovascular disease (1, 34, 63) as well as sleep disorders (14, 63). Though not all causes of obesity and cardiovascular diseases are lifestyle related, many are and can be reduced through proper nutrition and physical activity (24, 25, 49). Even small changes in cardiovascular fitness levels can reduce premature mortality rates (24, 25, 36, 80).
Despite well-known health issues facing LEP, exercise participation levels among officers remains low (69). A survey of Canadian police officers observed that a mere 17% of police officers engaged in regular physical activity a minimum of three times weekly. Some have cited that a lack of scientific knowledge as to how to properly program and progress through a strength and conditioning programs hinders physical fitness progress (69). One study found that over 50% of officers identified proximity to training as a major motivating factor in their decision to engage in health physical activity (56). Many officers report exhaustion and lack of time as barriers to adopting an exercise program (8). Norwegian researchers reviewed factors discouraging LEP from regular exercise during work hours with more than 1/3 of the survey respondents expressing that the opportunities on site for physical activity were of poor quality (40). In addition, a common reason for lack of physical activity is sheer exhaustion and fatigue (67) that is often associated with overtime hours (91). An average of 17.5 hours of overtime a month has been observed with some departments averaging close to 100 hours per month (91).
Health and Wellness Programs
Corporate health and wellness programs are common practice in medium to large businesses (7, 18, 46, 51, 54, 58, 73). Mattke et al. 2012 (50) found that 92% of businesses with 200 or more employees offered wellness programs in 2009. These programs have been said to create substantial costs savings in the form of reduced health care premiums and absenteeism reductions (7, 18, 46, 51, 54, 58, 73). Companies are reporting annual return on investment as high as 432% and Johnson and Johnson reportedly saved approximately $250 million in health care costs from 2002-2008 (18). A major focus for companies has been proactively converting high-risk health status employees to low-risk health status (18, 51, 73).
Health and wellness programs differ in approach but often include blood testing, health fairs, weight loss challenges, exercise instruction, disease management programs, biometric testing, nutrition counseling seminars, classes, stress management techniques, smoking cessation classes, and lifestyle evaluations. These programs are often holistic, targeting the improvement of multiple health factors (54).
Companies who experience success with corporate health and wellness programs often do so because a culture of wellness is created and sustained at all levels of employment (7). Also observed is buy-in from high level executives mirroring buy-in from lower level workers (7). Wellness directors are included in cabinet meetings and are treated as integral overseers of a vital functional area of the company (7). Lastly, companies who find success overcome objections, show empathy, and accommodate employees. Often, on-site exercise facilities were opened earlier and closed later to meet time schedule needs of employees (7).
Corporate America is investing more in the lives of employees yet LEP seem to be resistant to following such trends. In the 1990’s, Brodsky (12) challenged police agencies to adopt health and wellness initiatives (monthly meetings for all personnel regardless of rank) and offer onsite facilities to combat the cardiovascular issues facing LEP (12). Decision makers who create interventions to address the dire health concerns of LEP may make both socially and financially wise investments.
Police Health and Wellness Programs
In comparison to corporate study cases, there is a paucity of research discussing the availability of similar health and wellness programs for LEP. There is, however, a recognized need for such programs in law enforcement environments (10, 11, 12, 17, 34, 47, 61, 76, 81, 93). Moreover, unfit male officers have been found significantly more likely to miss work, due to sickness, than males with higher fitness levels (76).
Nutrition intervention programs have indicated successful results in police settings (11). A bi-monthly 15-week nutrition counseling program of 51 officers participated and experienced noteworthy success. Groups consisted of a control group receiving an information packet with nutrition information and an experimental group of officers who received nutrition counseling. Posttest measurements revealed that nutrition counseling had substantial positive health effects while the control group showed no change in health (11). In this case, mere information did not change behavior, but professional intervention did contribute to change. Results were so positive that the study led to the City of Austin, Texas adopting the program as part of its policy standards.
Other programs have targeted stress reduction in LEP populations with positive results (3, 47). McCarty et al. (47) studied 75 correctional officers by employing emotion self-regulation techniques to reduce stress and other measures. Post study levels of cholesterol, blood glucose, and blood pressure were all lowered (47). However, other studies could not correlate stress management programs to reductions in stress for LEP (59, 89).
In a study spanning 10 years of LEP, Quigly (62) found the health of police officers to be in worse physical shape than the general population and concluded that a national push to increase the development of and participation in fitness and health programs by LEP agencies is critical (62). To date, no such centralized program has emerged. Church and Robertson (17) surveyed state police agencies to determine what type of intervention programs are offered. The survey focused on five areas of wellness including physical health, stress management, mental health, nutrition, and drug and alcohol dependency. Of the 49 state agencies that responded by survey, 29 states offered at least one form of wellness intervention; none of the agencies offered all five areas (17).
Creating holistic health and wellness programs for LEP that targets both physiological and psychological health is recommended. However, implementing such programs may prove difficult. Law enforcement agencies operate independently and within the constraints of predetermined budgets (17). This rest of this review will focus on physical preparation interventions and offer recommendations for LEP populations to implement for this simple reason. These recommendations are scalable and practical to implement regardless of financial constraints.
Needs Analysis
Based on the available data, LEP may need higher levels of fitness and movement specific training to prepare for combat situations. Diet and exercise are intricately intertwined and cannot be considered mutually exclusive of each other. Training programs should consider common injuries specific to LEP personnel as well as common movements in combat and everyday service. In addition, training programs should start with a thorough assessment to determine imbalances and areas of weakness. Precincts that fail to screen candidates risk incurring long term disability costs, increased employee turnover, and poor officer productivity that ultimately puts the officer at risk (2).
Spinal Protection
Police officers are consistently in positions that have the potential to cause discomfort and result in spinal injuries. Extended periods of sitting, duty belts, protective vests, and mobile data terminals can cause postures to be frequently adjusted due to pain (32, 48). Special weapons and tactics (SWAT) operators often wear body armor, helmets, weapons, ammunition, supplies, and equipment belts that can weight up to 40 kilograms. Loads increase for officers carrying shields and battering rams. These loads are worn on the upper body creating the potential for injury to the spinal column (61). In addition to increased upper body loads, SWAT officers are often asked to hold perimeter positions for long periods of time, carrying and slinging rescue victims on one side of the body. They also hold objects like shields on one side of the body. These tasks require dynamic core strength in all anatomical planes to prevent injury to the spine (61). Unfortunately, core strength has been found to be low among (50% compared to national average) police officers (35, 61).
Cardiovascular Fitness
Creating basic physical preparation intervention programs to improve cardiovascular fitness levels in LEP will likely improve quality of life, extend life, and improve performance. From an intervention perspective, the goal is twofold. First and foremost, the aim of physical preparation intervention programs is to improve strength and conditioning levels so officers can maximally perform in the line of duty. Secondly, the purpose is to create enjoyable and sustainable programs that increase energy, reduce stress, and ultimately lower healthcare and absenteeism costs.
In the line of duty, LEP have been found to work at maximal intensity when situations arise (23, 21, 2). Eighty-eight percent of ride-along observers found that officers run at medium to maximum effort (23). They also observed high levels of maximal intensity when officers engage in pulling and pushing (72%), dragging, (66%) and lifting and carrying (57%; 23). Therefore, officers who maintain poor levels of aerobic fitness limit their ability to perform maximal anaerobic activities required of them in the line of duty. Improved aerobic conditioning decreases the time to recover after intense exercise and increases high power output over time (anaerobic threshold; 49). Therefore, departments who allow officers to maintain poor levels of fitness not only waste public money through high incurred healthcare costs, they also limit the abilities of their officers to apprehend suspects. Moreover, departments who neglect the importance of cardiovascular health do so “willfully”; despite the fact that aerobic and muscular endurance has been found to be the most important physical attributes according to seasoned LEP (43, 82).
Strength and Power
Ride along observers found that during physical altercations officers engage with maximal effort in pushing, twisting, controlling other persons, applying holds, wrestling, using wrist arm locks, forcing persons to the ground, punching, and lifting persons (23). Altercations observed in ride-alongs were violent 79% of the time. These altercations involved dealings with suspects that were heavier, taller, more physically fit, and were an average of seven years younger (23). The need for not only strength, but the ability to execute rapid and powerful movements is critically important, (1, 2, 20, 21) especially in older officers who annually lose strength and power due to aging. It is important to note that one-quarter of police officers aged 40-54 engage in high intensity situations a minimum of five times a year with the most frequent altercation being a struggle to arrest a resisting suspect (71). Strength is especially important in specialized tactical teams; since strength was found to be the most important trait for successful performance (20).
Speed and Agility
Police officers often engage in foot pursuits that can involve maneuvering around objects, running upstairs, and jumping over permanent structures such as ditches and walls (1). The need for speed combined with agility has caused domestic and foreign police forces to develop tests that incorporate duty specific movements (6, 19, 23). Specifically, surveyed SWAT officers ranked the ability to quickly clear a 6 foot or less obstacle as the second most important on the job physical task (21).
Nutrition and Body Composition
Increased body fat has been identified as a hindrance to job performance (21). Police officers have been shown to be overweight (19, 22, 61, 63, 67) and therefore face higher rates of injury by sheer increase in force on joints and soft tissues. Nutrition, exercise, and body composition are intricately intertwined. Success in one area and failure in another is a cause of frustration for many. The health issues in LEP are not merely associated with sedentary lifestyle and the high stress environment of police work as nutrition is part of the problem and must be carefully programmed alongside physical training variables.
Physical Preparation Intervention
Spinal Protection
Core strength has been identified as an integral component of an ideal fitness profile (35) yet police officers have been found to lack core strength (35, 61). Pryor et al. (61) found SWAT team members had lower levels of core strength when compared with the general population. Anti-extension, anti-lateral flexion, and anti-rotation exercises are recommended dynamic core training strategies (78).
Operations missions can increase body weight by 60-80 pounds (77). This amount of weight combined with changes in the center of gravity can cause injury in the lower back region. Therefore, strengthening the lower back muscles is recommended (77). Core training for breaching officers who knock down doors with rams will require more dynamic and explosive movements such as med ball tosses, overhead squats, hang cleans, and farmers carries (78).
Cardiovascular Fitness
Stave et al. (75) inferred that the greatest cost savings in health and wellness intervention is reduction in worker’s compensation premiums. Injuries, particularly in the lower limbs, tend to be a major cause of training days lost in basic training environments (66, 70).
Regali (65) studied over 260 Maine police cadets. The purpose of the study was to uncover the most common injuries cadets endure. Injuries related to running such as knee, shin, achilles, and stress fractures were high (57, 65). Other studies also found high levels of running in basic training to be associated with increased incidences of injury (13, 27, 26, 33, 37-39, 52, 57, 65-67, 70, 86)
Regali (65) indicated that a greater injury probability exists for cadets with lower levels of fitness. Rapid onset of training, especially in unfit individuals, increases chance of injury (27). Abnormal gait is another critical factor linked to higher rates of injury (13, 27).
Running long distances, most often 1600 meters (1.5 miles), is a common and still often used measure of cardiovascular fitness in police cadet academies and military environments (26, 33, 41, 45, 57, 64, 80, 86). The potential for injury during basic military training has been estimated to be threefold higher than in other military activity contexts (57).
Considering the aforementioned factors, running mileage in wellness interventions should be assigned carefully. Running could be the greatest threat of injury in basic cadet training, on the job duty, and in health and wellness interventions. Therefore, the following recommendations for running are provided for intervention groups and basic cadet training.
Firstly, group persons of like fitness together. Also known as ability based training (ABT), grouping officers to ability levels reduces injury by reducing the speed at which activities are accomplished. Participants can train according to their ability, not at a speed not necessarily accustomed, and make steady gains toward improving fitness. ABT often encompasses shorter and higher intensity running as opposed to longer running bouts and results show superior outcomes to traditional high mileage programs (29, 37-39, 57).
Secondly, reducing training volume and increasing intensity is recommended. High intensity intervals have been found to engender greater physiological aerobic responses than longer slower activities such as long periods of slow paced running in SWAT (31). Consequently, in police populations where age is correlated with lower levels of fitness (6), using short and high intense intervals in training (and basic training) is recommended to increase aerobic fitness and reduce chance of injury. High intensity interval training (HIIT) and training causing heart rates to rise higher than 90% cause greater aerobic adaptations (31, 49, 52).
Studies in military basic training corroborate this recommendation. Knapik et al. (39) compared two groups, one running 17 miles weekly with intervals and another running 38 miles weekly at a slower pace. Similar running improvements were made but the low mileage group had lower injury rates. In a similar study, Shaffer (68) compared two groups, one running 33 miles weekly and another 55 miles, and found both groups improved near identically in time but the lower mileage group incurred less injuries. Trank et al (86) found a lower mileage group running 26 miles weekly had better run time improvements than a 44-mileage group with less injuries.
Thirdly, testing should combine the first two recommendations. Traditional testing using 1.5 mile runs and longer may not be optimal tests, especially for less conditioned officers. Basic tests such as the 15-30 intermittent tests may be better options for LEP. This test, and other ABT tests like it, are shorter in duration and offer organizers the ability to group officers by fitness level. In addition to testing aerobic fitness, police officers should be tested globally across multiple fitness areas to incorporate duty specific chase-apprehend-carry actions in the field. These tests are defined as occupational physical assessment tests (OPAT) that vary by occupational skill sets. OPAT will be further discussed in the programming section.
Strength and Power
Past interventions have found success at improving maximal strength and power qualities. Lagestad et al. (41) found that over the course of a three-year study male officers improved in upper body strength measures but not cardiovascular measures.
Upper body strength measured by bench press strength has been correlated with improvements in police specific tests that involved the apprehension of suspects (74). However, an overemphasis on bench press strength has also been correlated with increased weight gain that has obvious cardiovascular and relative strength drawbacks (10, 61). Tarnklev and Widing (82) discovered that even though officers believed aerobic endurance was the most important physical quality necessary for police work, bench press strength was the most important training priority. This was despite max strength being designated as the 2nd least important physical quality needed in police work. These data give insight into the preferences of officers. Therefore, training plans should include some bench press, but programmed less often. SWAT officers ranked lifting weights greater than 150 pounds from the floor or knee height as the most important task on duty (21). Thus, programming deadlifting into strength work is advisable, especially for elite tactic teams.
These data suggest that motivating LEP to engage in strength work is less difficult than other tasks. The key to maintaining strength is providing opportunities during work to do so. Studies have found it imperative to create time for LEP to exercise during shift hours (40, 43, 55). This is precisely why interventions, internal or external, are so important for LEP. Creating opportunities for LEP to exercise during shift hours is paramount to successful interventions.
Lastly, because police officers experience tremendous amounts of stress and fatigue, reps and sets should be prescribed with total flexibility. Rate of perceived exertion (RPE) should replace exercise intensities (e.g. 85%). To coincide with RPE, the use of heart rate variability (HRV) monitors may also prove profitable. To date, very few studies have used HRV in tactical populations except for a study using HRV to augment pistol marksmanship (85). Lastly, LEP suffering from high blood pressure should be careful when engaging in upper body exercises due to the increases in blood pressure that is experienced during this type of activity (49).
Speed and Agility
Plyometric training has been shown to increase speed and agility qualities in athletes (5, 53, 84, 88). Due to the ease and cost effectiveness of implementing plyometric training, it is recommended that this component be included in training. Increases in performance up to 10-15% have been seen in plyometric activities that induce a stretch shortening cycle (SSC) response (87). Recommended volume for plyometric training consisting of frequency, volume, intensity, and rest are as follows: 2 times weekly, 40-60 total contacts, 2-3 sets of 4 to 6 repetitions with 1-3 minutes rest between sets and 72 hours rest between days (92).
Nutrition and Body Composition
Higher protein diets can prove very effective for weight loss goals as well as high retention rates (44, 55). A 12-week study in overweight police officers comparing hypocaloric diets supplemented with casein protein and whey protein revealed compelling results. Both groups lost substantial body fat and increased in strength measures (22). Providing nutritional information is not enough (11). Officers may need ongoing counseling to ensure proper nutrition guidelines are understood and properly implemented. Meal planning, especially for night shift officers is one of many topics likely to be uncovered through nutritional counseling.
Body mass index (BMI) is often a measure used to evaluate body composition. It is recommended that BMI not be used in the evaluation of LEP. One study done with recreationally trained men indicated that BMI explained little variance in 400-meter sprint times, 30-meter sprint times, obstacle course times, vertical jump, horizontal jump, pushups, sit-ups, and long distance running (29). Thus, when measuring body composition, it is recommended that accurate techniques such as dual energy X-ray absorptiometry (DEXA) or Bod Pod be used to ensure accurate results. Small sample sizes can be used for departments with smaller budgets. Other studies have used skinfold tests (19).
Programming
Combining fitness variables into periodization plans that increase both performance and engagement of LEP over time is the perhaps the most difficult part of interventions. Goals should be to increase job specific performance and overall health. A third goal that may be most important is to create sustainable programs aimed at transforming precincts into healthier cultures.
Improving Job Performance
Domestic and foreign LEP have moved toward OPAT tests that incorporate what Farenholtz and Holtz (23) defined as a “pursuit, arrest, and remove the problem” model. (6, 23, 79, 82). Dutch police officers must pass four tests, one of which includes a 226.5-meter sprint consisting of climbing obstacles and jumping over obstacles. The other tests are pushing and pulling a 200-kg cart over a distance of 3 meters and dragging a 48-kg dummy for 5 meters (79). Swedish officers must pass a near identical test (82). A Canadian officer test features a 400-meter sprint, the pushing and pulling of an 80-pound apparatus, squat thrusts, and the carrying of 45.5 kg weight over a 50-foot distance (23). It is recommended that a pursuit, arrest and remove the problem program be employed, tested, and measured due to the high level of correspondence to actual field work. These tests measure many fitness qualities at once and are simple to measure.
Improving Health
In addition to reducing healthcare and absenteeism costs, interventions should include exercise programming common to all fitness populations. Stationary bicycles, treadmills, squat racks, and dumbbells are suggested. Providing equipment on-site is recommended, but may not be feasible due to space and budget limitations. In such cases, providing memberships making it possible for officers to meet with intervention specialists, namely personal trainers and/or certified strength and conditioning specialists (CSCS), is recommended. It is strongly recommended that new recruits are indoctrinated early as research has indicated that officers who start lifestyle programs at early ages in their careers continue to exercise into middle age (72).
Periodization of Fitness Variables
In the context of athletic competition, periodization has been defined by Yuri Verhoshansky and Mel Siff as the long term cyclic structuring of training and practice to maximize performance to coincide with important competitions (90). For LEP personnel, every day is literally game day. In this case, plans will likely need to be mixed method plans, also known as conjugate plans, to maximize as many fitness variable as can be maximized without risk of injury or performance. Rather than cyclical programs designed to peak performance for specific events, plans may be better designed to improve performance and keep the interest of LEP high and engaged.
Structuring fitness plans for LEP over time requires expertise and knowledge of physiological processes. Increasing qualities in one area of fitness is often incompatible with other qualities. Moreover, the frequency and duration of aerobic training has an inverse relationship with strength and power results (30, 94). Hawley (30) attributes this relationship at the molecular level. The stimulation of mitochondrial biogenesis through aerobic conditioning may suppress protein synthesis needed for muscle repair from strength and hypertrophy training.
Basic recommendations for periodization are as follows: A) Due to the nature of police work, developing mixed method plans optimizing multiple fitness qualities simultaneously may be best. The 1988 football periodization plan by Charles Poliquin is considered, at least by this author, to be one of the simplest and practical mixed method approaches created (60). B) Only attempt to maximize one fitness quality at a time. Time can mean during a specific workout or on a separate day. Multiple qualities can be trained on the same day, but only one should be maximized. Ideally, fitness qualities should be trained on separate days, especially for LEP with higher levels of fitness. C) The performance variable seeking to be maximized should be trained first. Some argue that strength needs to be trained first and this is also a sound recommendation (28). D) Periodic testing reveals the efficacy of the program implemented. Crawley et al (19) studied police cadets over 16 weeks testing at 8 weeks and 16 weeks to determine program efficacy. Results at 8 weeks revealed increases in multiple fitness qualities; however, at 16 weeks little improvement was seen from week 8. Without testing, adaptations are assumed and not understood. When performance is stagnant, the cause for fatigue or even overtraining can be a potential reason. Introducing a program that creates additional fatigue on already stressed LEP defeats the purpose of intervention.
CONCLUSION
LEP are among the most important assets to local communities yet poor health pervades this segment of society. Even more perplexing, LEP must engage in maximum intensity activities but often do not have the necessary physical fitness levels necessary to accomplish such activities. Intervention, as defined by this review, is an intentional commitment to living healthy and optimizing job performance by investing in a program designed to deliver results. Corporate wealth is important but not nearly as important as the health and safety of those who maintain law and order; yet each year thousands of corporations invest millions of dollars in health and wellness programs whereas comparable investments in LEP environments is scarce.
This review identified five major physical needs based on the available research. These needs include spinal protection by increasing core strength, increasing cardiovascular fitness, increasing strength and power, increasing speed and agility, and providing nutrition counseling. Improving these needs through well designed periodization planning to improve job specific activities and general health are long term studies worth pursuing. Qualified health professionals hired internally or outsourced externally is recommended. Due to the fatigue LEP experience, unpredictable hours worked, and poor health conditions of LEP, it is not recommended that other forms of interventions be employed. These could include workshops and seminars that include PowerPoints and packets of information given to LEP with the hope of improvement. LEP offer their lives to defend their communities. It’s time to begin investing back into their lives.
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