Tactical athletes are individuals in service professions (eg, military, firefighters, law enforcement, and emergency responders) who operate in stressful and demanding scenarios to achieve their missions.1–3 Tactical athletes must meet significant fitness and physical performance requirements associated with their work.1–3 These athletes often work under life-threatening conditions, including burning buildings, wildfires, war zones, gun fire, and extreme weather conditions.1,3 Specifically in the fire service, firefighters are employed by one of three groups (municipalities, federal, and private) with work in settings combating structural (building) and wildland (nature) fires.3,4 Although characteristics vary within each employer type, all firefighters are governed by Occupational Safety and Health Administration (OSHA) standards requiring them to report mandated injuries resulting from the job.4–6 Work-related injuries and illnesses that are routinely reported to OSHA include a loss of consciousness, days away from work, restricted work, transfer to another job, or those that require medical treatment beyond first aid.6 Firefighters must follow the injury reporting process to receive workers' compensation benefits, including coverage of medical bills, lost wages, and disability.7
Firefighters are the first responders of our country, and to protect their livelihoods and perform their job to their maximum potential they wear heavy protective equipment and gear.3 The added weight from the equipment and gear, which can range between 45 and 75 pounds, increases the risk of musculoskeletal injuries (MSKIs) when having to operate in strenuous conditions.8 The clothing requirements of firefighters matched with the environmental exposures to heat, smoke, and chemicals can lead to fatigue causing slips, trips, and falls, resulting in MSKIs such as sprains and strains.9,10 Firefighting presents high risks for sustaining a MSKI, with overexertion and muscular strain accounting for 27.1% of all injuries.11 A firefighter's job includes strenuous physical demands and limited modified-work opportunities; therefore injury duration and risk of sustaining further injuries is higher.12 The repetitive bending, squatting, kneeling, and lifting firefighters perform has been shown to increase their risk for osteoarthritis.12 Research has noted that firefighters face an increase in perceived physical strain due to the postural demands and heavy lifting tasks along with poor perceived health and poor work ability due to symptoms associated with MSKIs.13 MSKIs are associated with cumulative factors, meaning they worsen over time if not properly cared for and put the firefighter at a greater risk for more injuries, which leads to physical impairment.12 MSKIs can cause economic strain and long-term physical repercussions, and may lead to early retirement.12,14 Long-term effects associated with MSKIs are more prevalent in firefighters as compared to other public safety and private sector workers due to the nature of a firefighter's job, leading to joint damage and permanent disability that reduces the firefighter's vitality in the profession.3,12 The multi-faceted environment a firefighter must navigate alludes to the importance of identifying the structural and cultural factors associated with MSKIs.
The National Fire Protection Association (NFPA) conducted a needs assessment that demonstrated only 27% of all fire departments have prevention and wellness programs.15 Previous research has proposed that prevention and wellness programs may help to lower the rate and risk of disability, while decreasing the cost of health care services and increasing public safety and protection.12,14 One avenue that is emerging with tactical athletes is the use of athletic trainers to assist in the health care delivery. Needs assessments are often completed to help an organization determine the needs or gaps between the organization's mission and the current state. It is important for athletic trainers to discover the similarities and differences between patient populations to uphold a high standard of care that caters to the needs of the population.
Although MSKI statistics in the fire service are available, there is limited research on how accurate and honest MSKI reporting is implemented, including the barriers a firefighter might face when choosing to report.11,16 Inadequate reporting behaviors increases the risk to a firefighter's longevity of serving due to delays in treatment.17 This can create a burden on not only the firefighter's health but their families, departments, health care systems, and national economies.17 Inadequate injury reporting compromises the accuracy of surveillance data and the identification of health and safety concerns related to workplace incidences.18 For policy makers and management to implement the most appropriate interventions to mitigate unsafe workplace conditions and ensure worker safety, challenges to injury reporting must be explored. Therefore, the aim of this study was to identify the barriers firefighters experience when reporting work-related MSKIs.
Methods
We used a cross-sectional survey design through a web-based survey platform (Qualtrics, Inc., Provo, UT) to sample active firefighters in the United States. This study was approved by the Indiana State University Institutional Review Board.
Participants
We recruited career and volunteer firefighters through public databases, snowball sampling, and word of mouth.19 The only inclusion criterion for the study was the firefighter had to be active in the fire service. We chose to recruit in this manner because no comprehensive database of firefighters in the United States exists. We contacted fire chiefs and fire chief organizations across the United States, asking them to distribute the survey to the firefighters currently serving their department.
Instrumentation
The online survey tool was adapted from a previous focus group study comparing the perceptions of fire chiefs and firefighters on the factors that contribute to MSKIs in the fire service.14 The participants responded to questions that assessed their current status as a fire-fighter, age, sex, years of experience, size of fire department, type of community they served, and if they had internal access to a health care provider (eg, physical therapist, athletic trainer) who could treat MSKIs and injury reporting habits. Additionally, the variables of interest were separated into two categories: perceived structural and cultural barriers to reporting MSKIs and perceived level of challenge of each self-selected barrier. The cultural and structural barriers included in this survey tool derived from the focus group study previously mentioned.14 For the purpose of this study, structural barriers were defined as factors beyond one's personal control that are part of the context or environment.20 For example, the fire service typically uses worker's compensation as part of the health care structure, whereas the barrier related to the structure would be difficulty filing worker's compensation claims. The cultural barriers were defined as factors that shape and guide a firefighter's life within the fire service.21 An example of a cultural barrier may be that a firefighter is fearful of the worst-case scenario when dealing with his or her MSKI and how it will affect his or her work and home life. Cultural barriers can impede workplace safety improvements due to a lack of focus and resources allocated to developing a safe reporting environment that is not punitive in nature.22
A group of five athletic trainers developed the survey instrument. The group was composed of both practicing clinicians (KAP, KNT) and researchers (ZKW, LEE, KEG) with experience providing patient care and studying the tactical athlete population. The group separated a list of 30 compiled barriers identified in previous work into two categories: structural and cultural barriers.14 First, the survey was content analyzed by an expert panel including two athletic trainers in the fire service and two active fire chiefs. Next, we shared the survey tool with the two athletic trainers to assess the appropriateness of the language used and questions included to conduct the content analysis. We asked the expert panel to provide suggestions for improvement. Once the feedback was received, the research team made necessary edits. Finally, the survey tool was sent to three different active fire service leaders (one fire chief and two battalion chiefs) to separate the barriers into the two categories. The fire service leaders were given a working definition of structural and cultural barriers. The fire service leaders were asked to drag and drop each barrier into the corresponding category that was most appropriate. After review, a consensus was obtained on the categorization of the barriers using 100% agreement from the fire service leaders, with the authors settling any two-thirds disagreements. There were 15 structural barriers and 15 cultural barriers included in the final instrument. Pilot testing was completed with a local fire department (n = 17) that was excluded from the final data analysis for survey flow and instrument face validation. Minor changes were made prior to survey distribution.
Procedures
For individuals who wished to volunteer for this study, an electronic informed consent and background on the study were presented via a web-based survey. Participants was presented with a list of the 15 cultural and 15 structural barriers and asked to select all that were considered a self-perceived barrier to reporting MSKIs in the fire service. Based on each selected barrier, participants proceeded to rate the level of challenge on a 4-point Likert scale ranging from slightly challenging (1) to extremely challenging (4), indicating how much that barrier impacted their ability to report MSKIs. Data collection concluded after 5 weeks of continuous recruitment from October to November 2018.
Statistical Analysis
Data were exported from the web-based survey platform and analyzed using a spreadsheet program (Microsoft Excel 2010; Microsoft Corporation, Redmond, WA). If participants exited the survey after consent was granted but did not complete the instrument, their partial data were excluded from the analyses. The mean, standard deviation, mode, frequency of mode, and percentages were calculated for each barrier and degree of challenge.
Results
Participants
A total of 382 firefighters from across the United States accessed the survey and 314 firefighters completed the survey (82% completion rate). Because we used snowball sampling, we could not calculate an access rate. The participants (age = 40 ± 9 years) were predominantly male (283 of 314, 90.1%), with an average of 17 years of experience in the fire service. Most of the participants (289 of 314, 92%) were active career fire-fighters. More than half of the firefighters served a city with a population of more than 100,000 (118 of 314, 37.6%) and metropolitan community with a population of more than 1 million (96 of 314, 30.6%). The other communities served were almost equally distributed as rural (49 of 314, 15.86%) and suburban (46 of 314, 14.89%). Complete demographic data are provided in Table 1.
Access to Health Care and Reporting Behaviors
More than half of the firefighters (179 of 314, 57%) had internal access to a health care provider. Many of the firefighters reported suffering from a MSKI off-duty and not reporting it to their superior (207 of 314, 65.9%), whereas few firefighters reported sustaining a MSKI off-duty and reporting it (96 of 314, 30.6%). There were different findings when asked if they had suffered from a MSKI on-duty and reported it; 64% (201 of 314) of the firefighters said they did report the injury, whereas 32.5% (102 of 314) did not report the injury.
Barriers
The most frequent barriers to MSKI reporting included accepting pain as a natural part of the job (167 of 314, 53.2%) and change in duty status, meaning being put on light duty or time off for injury healing (144 of 314, 45.9%). The firefighters perceived the following as the most challenging barriers to reporting MSKIs: lack of organizational support during the probationary period (8 of 17, 47.1%); lack of commitment to their family, meaning they do not receive the time they need with their family (20 of 44, 45.5%); medical services provided as not helpful (20 of 46, 43.5%); fear of the worst-case scenario, meaning the consequences that could follow a significant diagnosis or change in their health status that affects their work (35 of 84, 41.7%); and lack of benefits provided by the department (12 of 32, 37.5%). The firefighters who identified a lack of education of health care services (15 of 34, 44.1%) as a barrier to reporting MSKI perceived it as the only “slightly challenging” barrier. The cultural barriers that were selected as “very challenging” centered on the stigma of being a part of the brotherhood, such as not letting fellow firefighters down, accepting pain as part of the job, and fear of losing their job. Similarly, the structural barriers of a change in duty status and difficulty filing worker's compensation were frequent and moderately challenging barriers to reporting MSKIs. Table 2 provides the measures of central tendency for the complete list of barriers, whereas Tables 3–4 detail the perceived degree of challenge for the participants who selected the specific cultural and structural barriers, respectively.
Discussion
Reporting Behaviors
Identifying the barriers that prevent firefighters from reporting MSKIs is critical in determining sustainable solutions for reducing the long-term impact MSKI has on their health and well-being. It is important to report MSKIs to determine safety and environmental changes that need to be made to decrease risk of injuries. Injuries related to overexertion are reported to be 89% more costly than other causes of injury in firefighters.23 Injuries such as sprains and strains are 80% more costly than other injury outcomes compared to harmful exposures, extreme weather, struck by incidents, and contact with objects.23 Previous research states that the per-claim average worker's compensation cost of injury to firefighters was $5,168 and the average for injuries caused by overexertion was $9,715.23 Literature is sparse regarding the efficacy of workplace interventions, but the implementation of these interventions may help to decrease costs of injury to firefighters.23,24 To achieve the best state of physical, mental, and social well-being of firefighters in the workplace, the organization must have policies and procedures that address the health and safety of these individuals.25
This study assessed the cultural and structural barriers a firefighter may experience when reporting MSKIs. Firefighters indicated cultural barriers as more challenging than structural barriers to reporting MSKIs. Although firefighters seldom report a lack of education of health care services available as a barrier, the most frequent and challenging barriers allude to the fact that long-term health consequences of MSKIs may not be apparent to this population. According to this study's findings, 57% of the participants reported having internal access to a health care provider (eg, physical therapist). Approximately 14% of firefighters found that the medical services provided were not helpful and an extremely challenging barrier to firefighters reporting MSKIs. A lack of trust in a health care provider may cause a firefighter to avoid seeking out appropriate care when injury resolution is not achieved.26 The lack of trust may stem from the type of health care providers used within departments, which should be considered when working to find solutions to MSKI reporting challenges. Additionally, there needs to be a focus on MSKI education, because that is still the leading cause of injury within the fire service nationwide.11,27 Health care providers who focus on musculoskeletal health and safety, such as athletic trainers and physical therapists, may be ideally suited to assess and mitigate risks, encourage honest injury reporting, and treat the common MSKIs reported in the fire service.
Difficulty of the Barrier
In this study, the most challenging barriers to reporting MSKIs among firefighters were evenly distributed between structural and cultural barriers, which is an important consideration when tailoring health care to a multifaceted occupation. Firefighters' time commitment to their family was reported as the most challenging barrier found in this study. Commitment to family may be an important factor to consider when consequences of MSKIs may involve being put on light duty, resulting in pay reduction, lack of time off for personal healing, and lack of support when injured during probationary period as reported by firefighters in this study. Firefighters might not be able to afford the consequences of an injury if the appropriate resources are not available to them; therefore, they may be more willing to suffer long-term health implications rather than place their own financial security at risk.14
Under-reporting of injuries can result in delay of treatment, which then places a significant burden on employees and their families, departments, health care systems, and national economies.17 When examining other occupations with an injury under-reporting challenge, construction workers may provide insight into possible reasons for injury under-reporting.18 Firefighters and construction workers embody many similarities, such as being a male-dominated profession,18,28 the requirement of protective gear,3,29 and participation in labor-intensive work.3,30 Previous research also identified that construction workers dealt with work-related pain and injuries by using sick and vacation days instead of being put on light-duty and risk losing their income.18
Workers increase their risk for reinjury and additional lost time at work when they do not take the necessary time off to recover.31 Ensuring that firefighters have the necessary time off to heal and seek appropriate care is crucial to their long-term health. However, this cannot occur if firefighters are not transparent in injury reporting processes and procedures. As athletic trainers begin to provide health care services to public safety providers, the health care provider must consider whole-person care using the social determinants of health framework that explores how social context and income status influence key health issues.32
Injury Reporting and Career Longevity
The inability to determine if the injury was caused at work or otherwise is another commonly perceived barrier reported from the study's sample of active firefighters. Previous research has identified that firefighters admitted to not reporting every injury they sustained due to the lack of knowledge that they were hurt, and that they considered the injury to be minor.14 The perceived barriers to reporting MSKIs within our study paralleled identified barriers in construction workers.18 Construction workers felt that symptoms were not serious enough to seek help, and that the pain and discomfort were an inevitable consequence of the job.18 The failure to determine where the injury was caused and if the injury is too minor leads to firefighters perceiving the paperwork as burdensome and being seen as a liability or an adversary to their department for reporting minor injuries.14 The results of our study align similarly with previously identified perceptions of construction workers with injury reporting, including concerns about abandoning their team, fear of being labeled by their supervisors as unable to do their job or as a complainer, and belief that having symptoms was a sign of weakness.18
Previous responses from firefighters expressed thoughts on the possible loss of career due to not reporting or addressing MSKIs and the importance of documenting injuries that could become serious in the future.14 Although firefighters may recognize the importance of reporting injuries, the data identified that firefighters still do not report MSKIs because they perceive pain as a natural part of the job and fear jeopardizing their current or future career.14 Nonetheless, the latter may occur when firefighters exaggerate injuries to be put on lighter duty. The negative impacts of light duty may result in the firefighter feeling isolated at the fire station, which may result in the department spending extra money to temporarily fill the position.33
Firefighters in this study frequently reported injury-related work reduction/elimination as a challenging barrier to reporting their MSKIs. Firefighters being physically incapable of performing their job duties due to injury may lead to early retirement, causing firefighters to not report their injuries.33 Due to economic strain on the firefighters, it may be assumed that they would rather stay on full duty status and continue to receive their paychecks rather than report their injuries and be put on light duty or take a pay cut during their healing time. In 1990, the cost of absenteeism in the U.S. industry was approximately $12 billion.33 The cost of replacing the absentee workers was approximately $700 million per year to replace approximately 200,000 employees.33 When comparing the demographics of the U.S industry and national statistics of firefighters, they are similar in that they are middle-aged men.28,33 MSKIs are considered one of the major sources for disability and absenteeism in firefighters.11 Therefore, preventing and appropriately managing MSKIs early on may help to decrease injury-related work reduction and save large sums of money not only for fire departments but for the U.S. industry.
Implications for Clinical Practice
There are potential solutions to eliminating perceived barriers within the fire service to injury reporting. The ambiguity of MSKIs and the implications of that injury may lead to improper care and lack of education on the long-term effects of MSKIs. Therefore, firefighters may feel that accepting pain is a natural part of the job because of the lack of education on MSKIs and proper ergonomics within their job duties. Athletic trainers are skilled providers in the reduction of MSKIs and could serve as the link in improving injury reporting while reducing injury risk.34
There are various types and levels of interventions in preventing the risk of sustaining MSKIs in the work-place (Figure A, available in the online version of this article). Primary prevention is focused on reducing the stressors and risks within the environment, whereas secondary and tertiary prevention are limiting or managing the effect of the stressors on the individual.25 Primary prevention is adapting the environment to “fit” an individual or group of individuals.25 Some suggested strategies for implementing primary prevention include redesigning the work environment, providing social support and feedback, and building cohesive teams.25,33 Using primary prevention strategies may be a vehicle for cultural change within the fire service to help promote injury reporting.
One of the perceived barriers to injury reporting selected by firefighters in this study is a lack of social support such as home, family, and friends outside of work. Social support is a modifiable risk factor that can be addressed through primary prevention strategies.35 An increase in social support can aid in workers' abilities to resolve and handle stressors within their environment, which may help to increase injury reporting behaviors.35 Despite social support being focused on the firefighters' personal relationships outside of work, the fire department could evaluate and develop better policies that encourage injury reporting and provide appropriate benefits for injured employees. A comprehensive approach to workplace injury rate reduction programs may help to decrease the risk for sustaining a MSKI and providing the resources needed after responding to emotionally impactful calls.
To decrease the risk of MSKI, it is important to implement injury reduction programs aimed to improve injury reporting behaviors. With the integration of an athletic trainer in the fire service, the potential benefits include a reduction in injury time loss, assistance with worker's compensation claims, education on MSKIs, development of MSKI reduction programs, decrease in medical costs for the firefighters and departments, and the encouragement of reporting injuries without the fear of being put on light duty, or being seen as an adversary. When firefighters report injuries to athletic trainers or on-site health care providers, their health information is confidential. On-site health care providers may be able to keep firefighters on full duty by providing the appropriate resources and interventions to treating their muscular aches and pains.
The increase in departmental support and availability of resources can help to limit stressors within the work environment, thus possibly improving a firefighter's likelihood to report MSKIs.35 The decrease in environmental stress and increase in support can then lead to increased productivity and improvements in health.35 When there is an increase in positive health outcomes, the firefighter's longevity to serve increases and overall health costs decrease.33 The promotion of a healthy and positive environment that provides the necessary medical resources and support of the firefighters may help eliminate the cultural barriers to reporting MSKIs that the firefighters identify as being present. Focusing on properly educating the firefighters on their health and health care options, offering them support, and priori-tizing their health and well-being are some programmatic changes that should be made.35
Limitations and Future Research
The limitations of this study included recruitment methods through snowball sampling. There is no current mechanism to recruit firefighters nationwide through a national organization. There should be consideration in allowing the fire service population to be more accessible to continue quality improvement research related to improving the health of firefighters. For this study, a database was developed from online resources including contact information of fire chiefs from various states and regional fire organizations. This study studied the perceptions of firefighters who serve all types of communities, but it was difficult to gather a more representative sample to generalize firefighters across the United States. One aspect related to community type that should be explored is that the lack of MSKI reporting could be related to health literacy and, therefore, future directions should explore the role of health education in this process. Future research should be conducted on the effectiveness of intervention programs in addressing the barriers to injury reporting behaviors of MSKIs through the use of an on-site health care provider for health and wellness initiatives.
Conclusions
Firefighters indicated cultural barriers as more challenging than structural barriers to reporting MSKIs. Although firefighters seldom report a lack of education as a barrier, the most frequent and most challenging barriers allude to the fact that long-term health consequences of MSKIs may not be apparent to this population. Access to health providers, such as athletic trainers, may be a useful resource in educating and managing musculoskeletal injuries.
References
- Scofield DE, Kardouni JR. The tactical athlete: a product of 21st century strength and conditioning. Strength Condit J. 2015;37(4):2–7. doi:10.1519/SSC.0000000000000149 [CrossRef]
- Cameron KL, Driban JB, Svoboda SJ. Osteoarthritis and the tactical athlete: a systematic review. J Athl Train. 2016;51(11):952–961. doi:10.4085/1062-6050-51.5.03 [CrossRef]27115044
- Sefton JM, Burkhardt TA. Introduction to the tactical athlete special issue. J Athl Train. 2016;51(11):845. doi:10.4085/1062-6050-51.12.16 [CrossRef]
- Guidotti TL, Clough VM. Occupational health concerns of firefighting. Annu Rev Public Health. 1992;13(1):151–171. doi:10.1146/annurev.pu.13.050192.001055 [CrossRef]1599583
- FireRecruit.com. Know the 3 firefighting employer types. https://www.firerescue1.com/fire-career/articles/507293-Know-the-3-fire-fighting-employer-types/. Accessed February 20, 2019.
- U.S. Department of Labor. Occupational Safety Health Administration injury and illness recordkeeping and reporting requirements. Washington, DC: U.S. Bureau of Labor Statistics; 2011. https://www.osha.gov/recordkeeping/
- Sengupta I, Reno VP, Burton JF Jr, Baldwin ML. Workers' compensation: Benefits, coverage, and costs, 2010. Washington, DC: National Academy of Social Insurance; August2012. https://www.nasi.org/research/2012/report-workers-compensation-benefits-coverage-costs-%E2%80%93-2010
- Sobeih TM, Davis KG, Succop PA, Jetter WA, Bhattacharya A. Postural balance changes in on-duty firefighters: effect of gear and long work shifts. J Occup Environ Med. 2006;48(1):68–75. doi:10.1097/01.jom.0000181756.38010.d2 [CrossRef]16404212
- Heineman EF, Shy CM, Checkoway H. Injuries on the fireground: risk factors for traumatic injuries among professional fire fighters. Am J Ind Med. 1989;15(3):267–282. doi:10.1002/ajim.4700150304 [CrossRef]2929616
- Kincl LD, Bhattacharya A, Succop PA, Clark CS. Postural sway measurements: a potential safety monitoring technique for workers wearing personal protective equipment. Appl Occup Environ Hyg. 2002;17(4):256–266. doi:10.1080/10473220252826565 [CrossRef]11942669
- Haynes HJ, Molis JL. United States firefighter injuries-2017. Quincy, MA: National Fire Protection Association, Fire Analysis and Research Division; 2018.
- Seabury SA, McLaren CF. The frequency, severity, and economic consequences of musculoskeletal injuries to firefighters in California. Rand Health Q. 2012;2(3):4.28083263
- Lusa S, Punakallio A, Luukkonen R, Louhevaara V. Factors associated with changes in perceived strain at work among fire-fighters: a 3-year follow-up study. Int Arch Occup Environ Health. 2006;79(5):419–426. doi:10.1007/s00420-005-0059-2 [CrossRef]
- Conrad KM, Balch GI, Reichelt PA, Muran S, Oh K. Musculoskeletal injuries in the fire service: views from a focus group study. AAOHN J. 1994;42(12):572–581. doi:10.1177/216507999404201201 [CrossRef]7893285
- National Fire Protection Association. Fourth needs assessment of the US fire service. Quincy, MA, NFPA Research; 2015. https://www.nfpa.org/-/media/Files/News-and-Research/Fire-statistics-and-reports/Emergency-responders/Needs-Assessment/OSFourth-NeedsAssessment.ashx
- Haynes HJ, Molis JL. United States firefighter injuries-2014. Quincy, MA: National Fire Protection Association. Fire Analysis and Research Division; 2015.
- Scherzer T, Rugulies R, Krause N. Work-related pain and injury and barriers to workers' compensation among Las Vegas hotel room cleaners. Am J Public Health. 2005;95(3):483–488. doi:10.2105/AJPH.2003.033266 [CrossRef]15727981
- Moore JT, Cigularov KP, Sampson JM, Rosecrance JC, Chen PY. Construction workers' reasons for not reporting work-related injuries: an exploratory study. Int J Occup Saf Ergon. 2013;19(1):97–105. doi:10.1080/10803548.2013.11076969 [CrossRef]23498712
- Sadler GR, Lee HC, Lim RS, Fullerton J. Recruitment of hard-to-reach population subgroups via adaptations of the snowball sampling strategy. Nurs Health Sci. 2010;12(3):369–374. doi:10.1111/j.1442-2018.2010.00541.x [CrossRef]20727089
- Altheide DL. Women and Minority Groups: What Is a Structural Barrier?Arizona State University; 1999.
- Schaefer RT. Sociology: A Brief Introduction. New York: McGraw-Hill; 2006.
- Kohn LT, Corrigan J, Donaldson MS. Ebook Central—Academic C, eBook Academic Subscription Collection—North A. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000.
- Walton SM, Conrad KM, Furner SE, Samo DG. Cause, type, and workers' compensation costs of injury to fire fighters. Am J Ind Med. 2003;43(4):454–458. doi:10.1002/ajim.10200 [CrossRef]12645102
- Gyllensvärd H. Cost-effectiveness of injury prevention: a systematic review of municipality based interventions. Cost Eff Resour Alloc. 2010;8(1):17. doi:10.1186/1478-7547-8-17 [CrossRef]
- Cartwright S, Cooper CL. Managing Workplace Stress. Vol 1. Thousand Oaks, CA: Sage Publications; 1997.
- Ozawa S, Sripad P. How do you measure trust in the health system? A systematic review of the literature. Soc Sci Med. 2013;91:10–14. doi:10.1016/j.socscimed.2013.05.005 [CrossRef]23849233
- Frost DM, Beach TA, Crosby I, McGill SM. Firefighter injuries are not just a fireground problem. Work. 2015;52(4):835–842. doi:10.3233/WOR-152111 [CrossRef]26409354
- DataUSA. Firefighters. 2018. https://datausa.io/profile/soc/332011. Accessed March 2, 2019.
- Huang X, Hinze J. Analysis of construction worker fall accidents. J Constr Eng Manage. 2003;129(3):262–271. doi:10.1061/(ASCE)0733-9364(2003)129:3(262) [CrossRef]
- Parham S, Mirzaei R, Ansari H. Assessing the risk factors for musculoskeletal disorders in construction workers using PATH, case study: construction project. Iran J Health Saf Environ. 2017;4(2):716–721.
- Pransky G, Snyder T, Dembe A, Himmelstein J. Under-reporting of work-related disorders in the workplace: a case study and review of the literature. Ergonomics. 1999;42(1):171–182. doi:10.1080/001401399185874 [CrossRef]9973879
- Snyder Valier AR, Bacon CEW, Lam KC. Disablement model and health-related quality of life classification for patient-reported outcomes measurement information system (PROMIS) instruments. J Athl Train. 2018;53(12):1206–1213. doi:10.4085/1062-6050-331-17 [CrossRef]
- Danna K, Griffin RW. Health and well-being in the workplace: a review and synthesis of the literature. J Manage. 1999;25(3):357–384. doi:10.1177/014920639902500305 [CrossRef]
- Henderson J. The 2015 Athletic Trainer Practice Analysis Study. Omaha, NE: Board of Certification; 2015.
- Israel BA, Baker EA, Goldenhar LM, Heaney CA, Schurman SJ. Occupational stress, safety, and health: conceptual framework and principles for effective prevention interventions. J Occup Health Psychol. 1996;1(3):261–286. doi:10.1037/1076-8998.1.3.261 [CrossRef]9547051
Participant Demographics
| Variable | Frequency | Percent | Minimum | Maximum | Mean ± SD |
|---|
| Age | – | – | 18 | 74 | 40 ± 10 |
| How many years of experience do you have as a firefighter? | – | – | 1 | 58 | 17 ± 10 |
| What is your sex? | | | | | |
| Male | 283 | 90.1 | | | |
| Female | 24 | 7.6 | | | |
| Prefer not to answer | 2 | 0.6 | | | |
| Missing | 5 | 1.6 | | | |
| What type of community do you primarily serve as a firefighter? | | | | | |
| Metropolitan: population > 1 million) | 96 | 30.6 | | | |
| City: population > 100,000 | 118 | 37.6 | | | |
| Suburban | 46 | 14.6 | | | |
| Rural | 49 | 15.6 | | | |
| Missing | 5 | 1.6 | | | |
| Do you have access to a health care provider internally with the fire department? | | | | | |
| No | 120 | 38.2 | | | |
| Yes | 179 | 57.0 | | | |
| Missing | 15 | 4.8 | | | |
Firefighters' Frequency of Self-Perceived Barriers to Reporting Musculoskeletal Injuries in the Fire Service
| Variable | Category of Barrier | Frequency of the Mode |
|---|
| Race/ethnicity | Cultural | 2/314 (0.6%) |
| Leadership discourages reporting | Structural | 12/314 (3.8%) |
| Lack of access to health care services | Structural | 16/314 (5.1%) |
| Nearing retirement | Cultural | 16/314 (5.1%) |
| Lack of organizational support during probationary period | Cultural | 17/314 (5.4%) |
| Lack of fire department financial resources | Structural | 21/314 (6.7%) |
| Lack of knowledge in reporting structure | Cultural | 25/314 (8.0%) |
| Ease of scheduling appointments | Structural | 28/314 (8.9%) |
| Lack of knowledge about when to seek care | Cultural | 28/314 (8.9%) |
| Lack of benefits (eg, health insurance) | Structural | 32/314 (10.2%) |
| Lack of education of health care services available | Structural | 34/314 (10.8%) |
| Commitment to family | Cultural | 44/314 (14.0%) |
| Time away from the job needed to report | Structural | 45/314 (14.3%) |
| Medical services provided are not helpful | Structural | 46/314 (14.6%) |
| Poor communication | Structural | 46/314 (14.6%) |
| Fear of discipline from supervisor | Structural | 50/314 (15.9%) |
| Inadequate support from local authorities (eg, human resources, city officials) | Structural | 60/314 (19.1%) |
| Not getting time off for personal healing | Structural | 62/314 (19.7%) |
| Embarrassment of condition | Cultural | 63/314 (20.1%) |
| Fear of the worst case scenario | Cultural | 84/314 (26.8%) |
| Home treatments are sufficient to deal with the problems (eg, medicine, ice, heat pad, meditation) | Cultural | 85/314 (27.1%) |
| Pay reduction/unable to take off without pay | Structural | 86/314 (27.4%) |
| Absenteeism as a result of the injury | Cultural | 90/314 (28.7%) |
| Stigma of being a healthy and fit firefighter | Cultural | 92/314 (29.3%) |
| Jeopardizing current and/or future career | Cultural | 98/314 (31.2%) |
| Feeling of letting fellow firefighters down | Cultural | 101/314 (32.2%) |
| Difficulty filing worker's compensation claim | Structural | 126/314 (40.1%) |
| Inability to determine if the injury was caused at work or otherwise | Cultural | 140/314 (44.6%) |
| Change in duty status | Structural | 144/314 (45.9%) |
| Accepting pain as a natural part of the job | Cultural | 167/314 (53.2%) |
Firefighters' Perceived Challenge Related to Cultural Barriers With Reporting Musculoskeletal Injuries in the Fire Service
| Variable | Mode | Frequency of the Mode | Mean ± SD |
|---|
| Commitment to family | 4 | 20/44 (45.5%) | 3.30 ± .80 |
| Lack of organizational support during probationary period | 4 | 8/17 (47.1%) | 3.12 ± 1.0 |
| Fear of the worst-case scenario | 4 | 35/84 (41.7%) | 2.93 ± 1.1 |
| Feeling of letting fellow firefighters down | 3 | 39/100 (39.0%) | 2.82 ± .93 |
| Jeopardizing current and/or future career | 3 | 33/98 (33.7%) | 2.72 ± .98 |
| Stigma of being a healthy and fit firefighter | 3 | 33/92 (35.9%) | 2.68 ± .90 |
| Absenteeism as a result of the injury | 3 | 35/90 (38.9%) | 2.66 ± .88 |
| Lack of knowledge about when to seek care | 3 | 12/28 (42.9%) | 2.57 ± .92 |
| Race/ethnicity | 2 | 1/2 (50.0%) | 3.00 ± 1.4 |
| Inability to determine if the injury was caused at work or otherwise | 2 | 51/140 (36.4%) | 2.71 ± .96 |
| Embarrassment of condition | 2 | 22/63 (34.9%) | 2.70 ± .94 |
| Accepting pain as a natural part of the job | 2 | 61/166 (36.7%) | 2.63 ± .88 |
| Lack of knowledge in reporting structure | 2 | 8/25 (32.0%) | 2.56 ± 1.0 |
| Nearing retirement | 2 | 7/16 (43.8%) | 2.56 ± 1.0 |
| Home treatments are sufficient to deal with the problems (eg, medicine, ice, heat pad, meditation) | 2 | 35/84 (41.7%) | 2.29 ± .99 |
Firefighters' Perceived Challenge Related to Structural Barriers With Reporting Musculoskeletal Injuries in the Fire Service
| Variable | Mode | Frequency of the Mode | Mean ± SD |
|---|
| Medical services provided are not helpful | 4 | 20/46 (43.5%) | 3.22 ± .81 |
| Lack of benefits (eg, health insurance) | 4 | 12/32 (37.5%) | 3.06 ± .88 |
| Inadequate support from local authorities (eg, human resources, city officials) | 3 | 22/60 (36.7%) | 3.03 ± .86 |
| Pay reduction/unable to take off without pay | 3 | 37/85 (43.5%) | 2.96 ± .87 |
| Lack of access to health care services | 3 | 6/16 (37.5%) | 2.94 ± .93 |
| Not getting time off for personal healing | 3 | 21/62 (33.9%) | 2.85 ± .92 |
| Lack of fire department financial resources | 2 | 8/21 (38.1%) | 2.81 ± .93 |
| Poor communication | 2 | 18/46 (39.1%) | 2.80 ± .91 |
| Leadership discourages reporting | 2 | 4/12 (33.3%) | 2.67 ± 1.2 |
| Difficulty filing worker's compensation claim | 2 | 45/126 (35.7%) | 2.67 ± .98 |
| Change in duty status | 2 | 54/144 (37.5%) | 2.65 ± .88 |
| Time away from the job needed to report | 3 | 16/45 (35.6%) | 2.51 ± .94 |
| Fear of discipline from supervisor | 3 | 22/50 (44.0%) | 2.34 ± .94 |
| Ease of scheduling appointments | 2 | 11/28 (39.3%) | 2.18 ± .90 |
| Lack of education of health care services available | 1 | 15/34 (44.1%) | 1.82 ± .90 |