Perceived Barriers to Musculoskeletal Injury and Illness Reporting in the Fire Service

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.

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.

Table 1: Participant Demographics

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.

Table 2: Firefighters' Frequency of Self-Perceived Barriers to Reporting Musculoskeletal Injuries in the Fire Service

Table 3: Firefighters' Perceived Challenge Related to Cultural Barriers With Reporting Musculoskeletal Injuries in the Fire Service

Table 4: Firefighters' Perceived Challenge Related to Structural Barriers With Reporting Musculoskeletal Injuries in the Fire Service

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.