AMA Journal of Ethics^®

Health fairs are paragons of goodwill: generally free, they are usually provided by well-intentioned individuals and organizations with the goal of improving the health of a community, often one that is underserved. For example, a group of health professions students screen for high blood pressure at a homeless shelter, intending to improve the health and lives of an underserved and disenfranchised group. This health fair is conducted by volunteers, free to participants, and held in the common room of the shelter after clients have checked in for the night; they are free to participate or ignore the students.

On the surface, health fairs like this one appear to be ideal public health interventions, all benefit and little or no harm. As such, however, they warrant a certain degree of scrutiny to ensure they are ethical—that is, that the anticipated benefits outweigh any anticipated harms. Had the students who conducted the fair intended to improve the health of the shelter’s clients—that is, had they intended the event to be a public health intervention—they should have addressed the ethical consequences of the fair before holding it.

This homeless shelter scenario raises the question of whether in fact these fairs ought to be viewed as public health programs or interventions rather than as student training or recruitment activities, community relations events, local business promotions, or any number of activities with a range of other motivations and objectives. There are several compelling arguments for viewing them as public health interventions. First, the students in question clearly intended to use their skills to improve the health of the homeless participants in some manner. This is true of most fairs; they are directed toward some community with the intention of improving its health through interventions such as education and screening.

Another reason to view fairs as public health programs is that they often fill that need for many groups of people; the health fair at the shelter, for example, may be the only contact with health care professionals for some of the people who sleep there and perhaps even the first time they have had their blood pressure measured. Perhaps the most important reason for treating health fairs as public health interventions is that those who attend them view them as such. Some of the participants in the shelter may drop by because they are curious or bored or to pass time, but many attend because they believe it will provide something of value to their health.

If the students’ event at the shelter is a public health intervention, intended to improve the health of the residents, then standards such as those Nancy Kass proposes in “An Ethics Framework for Public Health” ought to guide its development [1]. And, if these students are well-intentioned and very much desire to improve the health of their target population, they might consider providing services that will increase the impact of the health fair.

One such service is follow-up after the event has concluded. Kass asserts, moreover, that ethical scrutiny of a public health intervention ought to be proportional—the greater the possible benefits and burdens of the intervention, the greater the scrutiny warranted [1]. Thus, adding follow-up to this health fair to improve effectiveness of the event also necessitates greater attention to the ethical concerns raised by the additional services.

We will examine what these concerns might be and how to best balance the benefits and potential harms that providing follow-up at a community health fair might include.

Potential Benefits and Harms of Follow-up to Health Fairs

One potential benefit of follow-up from a health fair is simply the act of reminding a participant of what he or she saw and learned at the fair. Behavior change is difficult and not likely to be successful with a one-time exposure to the recommendations at a health fair [2, 3]. A recent prospective study analyzed brief, personalized follow-up counseling for 15 months after a health fair [4]. The counseling involved four calls over 3 months to discuss and set health goals, check progress and provide assistance, and evaluate progress. These short follow-up calls reduced the percentage of participants who were obese or overweight and improved self-reported health status, dietary choices, and exercise habits [4]. The study also noted that these improvements occurred after the initial follow-up phone calls, suggesting that the one-time health fair had not been effective in producing the desired changes.

Beyond reminding participants of healthy behaviors introduced at the fair, follow-up gives them individualized attention that is particularly important if the participant does not have access to regular health care and preventive health resources or a trusted health care provider. Event participants can check a box or sign up if they are interested in receiving follow-up, which is what was done in this study, so that follow-up is a voluntary option and not an undesired intrusion.

A third benefit of follow-up is connecting fair participants to resources and information. If a participant needed a health care resource about which the health fair did not have information, someone from the fair could get back in touch with that participant to give him or her the details. This happens often at screenings at homeless shelters in Minneapolis, such as the one mentioned earlier.

More than one study has found that follow-up after health fairs improved disease outcomes by providing referrals to appropriate care. Lucky et al. found that a one-time follow-up phone call to participants with high blood pressure (HBP) increased the percentage that made appointments with their primary care physicians (PCPs) [5]. Of those who saw their primary physicians, 30 percent required BP medication or changes to their current BP medication, suggesting that even participants who are already seeing a PCP benefited from the screening and prompting [5]. Another study found that health fairs were integral in referring participants with elevated BP to primary physicians [6]. These participants who saw a PCP after the health fair averaged a fifteen-point decrease in their blood pressure.

Possible drawbacks of follow-up after health fairs include the time and money spent on a small percentage of fair participants who indicate they want further contact, as these resources could be used for screening a large number at another fair. The studies cited above require far more resources than a 1-day health fair. For example, the follow-up in the study by Dong-Chul Seo involved four calls for individualized counseling from a public health nurse to each participant over a 15-month period [4]. This is a significant commitment of time and resources. Similarly, in the study by Lucky et al., all participants with high blood pressure readings received a follow-up call, with interpreters as needed, to prompt them to see their PCP [5].

As the level of health-fair services increases, so does concern that participants view the health fair as a substitute for regular health care. Participants might feel that having their blood pressure taken at a health fair means they do not have to continue visits to their PCPs. This concern might be heightened if the health fair involved follow-up that imparted a false sense of fully individualized care and comprehensive care.

Most important, follow-up adds another level of care and thus of participant risk, including many of the risks that come with any kind of health care and range from issues such as inaccurate results and measurements to the loss of privacy or confidentiality. (Where, for example, does a homeless person receive confidential health information?) Introducing these risks carries with it a greater need for the protection of the participant’s autonomy and rights. This protection is best provided through informed consent, which, we believe, ought to be a part of a health fair if follow-up is provided. Benefits and risks should be discussed as in any health care encounter, and consent obtained.

Going through the informed consent process during a health fair seems particularly cumbersome, however, and somewhat impractical, given the number of attendees at many of these events. Informed consent also introduces volunteer training requirements, literacy and decisional capacity issues, and myriad resource issues.

It seems, then, that one of the central assertions of Kass’s thesis—that of proportionality—is appropriate in approaching health fairs. Adding follow-up adds great benefit to the effectiveness of the fair, but raises corresponding concerns that must be addressed in evaluating the full program. The most important concern raised is that providing this additional service carries patient risks and thus requires a consent procedure.