Sleep problems, depression, substance use, social bonding, and quality of life in professional firefighters.

Abstract

Little attention has been given to factors contributing to firefighters' psychosomatic well-being. The purpose of this descriptive study was to examine such contributing factors in a sample of professional firefighters.
Measures assessing sleep, depression, substance use, social bonding, and quality of life were examined in 112 firefighters.
Overall, many firefighters reported sleep deprivation (59%), binge drinking behavior (58%), poor mental well-being (21%), current nicotine use (20%), hazardous drinking behavior (14%), depression (11%), poor physical well-being (8%), caffeine overuse (5%), or poor social bonding (4%).
Small-to-medium correlations were identified between sleep deprivation, depression, physical/mental well-being, and drinking behaviors. High-risk behaviors that impact psychosomatic well-being are prevalent in professional firefighters, which require environmental and individual-based health promotion interventions. The inter-correlation relationships between such behaviors, therefore, need to be explored in further details.

Full text

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ORIGINAL ARTICLE
Sleep Problems, Depression, Substance Use, Social Bonding,
and Quality of Life in Professional Firefighters
Mary G. Carey, PhD, Salah S. Al-Zaiti, MS, Grace E Dean, PhD, Loralee Sessanna, DNS, and
Deborah S. Finnell, DNS
Objective: Little attention has been given to factors contributing to fire-
fighters’ psychosomatic well-being. The purpose of this descriptive study
was to examine such contributing factors in a sample of professional fire-
fighters. Methods: Measures assessing sleep, depression, substance use,
social bonding, and quality of life were examined in 112 firefighters.
Results: Overall, many firefighters reported sleep deprivation (59%), binge
drinking behavior (58%), poor mental well-being (21%),current nicotine use
(20%), hazardous drinking behavior (14%), depression (11%), poor physi-
cal well-being (8%), caffeine overuse (5%), or poor social bonding (4%).
Conclusions: Small-to-medium correlations were identified between sleep
deprivation, depression, physical/mental well-being, and drinking behaviors.
High-risk behaviors that impact psychosomatic well-being are prevalent in
professional firefighters, which require environmental and individual-based
health promotion interventions. The inter-correlation relationships between
such behaviors, therefore, need to be explored in further details.
P
the low control nature of the job.1Anxiety and posttraumatic stress
disorders are prevalent in the professional firefighters’ population
and constitute a dominant area of investigation.2Limited attention
hasbeengiventodescribingfactorsthatcancontributetofirefighters’
job performance and overall well-being, such as sleep problems,
depression, substance use, social bonding, and quality of life.
Sleep disturbance, fatigue, and work-related accidents are
common among shift workers3who typically work 8-hour rotating
shifts (eg, daytime/night time). However, in many fire departments,
extended rotating shift of 10-hour days/14-h nights are common
instead of the standard three 8-hour shift rotating schedule. Evi-
dence suggests that although extended rotating shifts do not add
any additional health hazards beyond that of the standard 8-hour
shift,4fatigue, decreased alertness, and poor mood scores were more
prevalent among firefighters working night shifts.5In fact, working
time was found to be more predictive of impaired alertness and in-
creased occupational accidents. For instance, sleep disturbance was
prevalent beyond working time exceeding 50 hours per week and
occupational accidents were four-fold more prevalent beyond work-
ing time exceeding 70 hours per week.3Current research indicates
that sleep deprivation (<4–6 hour of sleep in 24 hour) is associ-
ated with decreased vigilance, alertness, and mental performance;
increased sleepiness; fatigue, and depression; poor quality of life;
andincreasedriskforcardiovascularevents,digestivedisorders,obe-
sity, diabetes, obstructive sleep apnea, altered immune response, and
malignancies.6However, the association between patterns of sleep
rofessional firefighting is a strenuous and unique occupation
due to the high levels of stress and risk involved as well as
From the School of Nursing, University at Buffalo (Drs Carey, Dean, and Finnell
and Mr Al-Zaiti), School of Nursing, D’Youville College (Dr Sessanna), and
Center for Integrated Healthcare, VA Western New York Healthcare System
(Dr Finnell), Buffalo, NY.
Address correspondence to: Mary G. Carey, PhD, RN, The State University of
New York at Buffalo, School of Nursing, 209 Wende Hall, Buffalo, NY 14214
(mgcarey@buffalo.edu).
Copyright
Medicine
DOI: 10.1097/JOM.0b013e318225898f
C ? 2011 by American College of Occupational and Environmental
and substance use within the social context of firefighters’ popula-
tion and the overall impact on depression, quality of life and social
bonding need further investigation.
In the general population, the rates of posttraumatic stress
disorders and depression might be as low as 1.9% and 10%, re-
spectively. Yet, higher rates are seen in firefighters and other rescue
workersexposedtohumandisasters,17%and22%forposttraumatic
stress disorders and depression, respectively.2Experienced firefight-
ers are more likely to be exposed to human disasters given their
time in the role. Yet, it has been found that there is a linear posi-
tive relationship between years of job experience as a firefighter and
levels of traumatic stress and depression when comparing experi-
enced firefighters with new recruits,7that is, experienced firefighters
were more likely to report lower levels of social support and self-
esteem. Amount and variance of workload, group conflicts, social
support, role ambiguity, and self-esteem were all found to be predic-
tive of depressive symptoms among firefighters.8Nevertheless, job
strain and depression has been repeatedly linked to increased risk
of cardiovascular mortality,9which was found to be as high as 44%
in professional firefighters and four-fold risk when compared with
other first responders.10,11Assessing depressive symptoms in fire-
fighters, therefore, is an important initial step in understanding the
mental health needs of this population and preventing adverse phys-
ical and psychosocial health-related events. Additional concerns is
that depression, as well as susceptibility to stress, might increase the
risk of suicidal behavior, but may also have reciprocal influences
with alcohol drinking patterns.12
Low levels of alcohol consumption have been associated with
relief of anxiety.13A concern, however, is when alcohol consump-
tion becomes a hazardous behavior. Hazardous drinking places the
firefighter and others at risk. Alcohol consumption behavior among
persons and those in their social networks is highly correlated,14
concerning for a group of firefighters who are joined together for ex-
tended periods of time. In similar populations (eg, military), heavy
drinking pattern can be as high as 67% prevalent among men and
9% among women, with binge drinking pattern occurring in 48% of
men and 31% of women,15both patterns were higher than the gen-
eral population. Little attention has been given to the prevalence and
pattern of alcohol consumption in the social network of firefighters.
Other modifiable risk behaviors among firefighters include cigarette
smoking and coffee consumption. As central nervous system stim-
ulants, caffeine and nicotine use result in increased alertness, mild
euphoria, muscle relaxation, and increased psychomotor activity.16
Caffeine doses ranging from 2.5 to 7 mg/kg seem to improve high-
intensityexercisesperformance,1however,giventheunpredictability
of the job emergencies combined with rotation duty shifts that may
span 16 hours at a time, the normal sleep patterns of firefighters can
be disrupted by caffeine.
The concept of brotherhood as social bonding and connection
is deeply rooted among firefighters.17Brotherhood has been defined
by firefighters as a historical, traditional, and universal ideal char-
acterized by inherent dedication, love, respect, and support for one
another, living by a code of unspoken duty, trust, honor, and loy-
alty, and the establishment of membership and close relationships,
connections, and bonds.17Firefighters develop close social bonds
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JOEMrVolume 53, Number 8, August 2011Psychosomatic Well-being of Professional Firefighters
and connections with one another as a result of living in the fire-
house and working closely together for extended periods of time
when scheduled for duty. The social bonds and connections among
firefighters and within the firehouse are important factors in amelio-
ratingdistress.7Ironically,somestudiesstillsuggestthatexperienced
firefighters might have lower levels of social support making them
more vulnerable to depression and stress.7,8It is important to note
however that despite understanding among firefighters regarding the
significance of brotherhood as social bonding and connection, stud-
ies exploring social bonds and connection among firefighters are
limited.
In summary, the assessment of high-risk behaviors that can
be modified to promote health and well-being among firefighters
has received little attention. The impact of sleep deprivation, depres-
sion,substanceuse(alcoholandcaffeineconsumption,nicotineuse),
social bonding and connection, and quality of life on the psychoso-
matic well-being of professional firefighters needs further explo-
ration. Therefore, this descriptive study was conducted to examine
the prevalence and complex relationships between sleep depriva-
tion, depression, substance use, social bonding, and quality of life in
professional firefighters.
METHODS
Subjects for this investigation were enrolled in the Surveying
and Assessing Firefighters Fitness and Electrocardiogram study, a
National Institute of Health-funded cross-sectional descriptive study
to characterize firefighters hemodynamic responses while on-duty.18
The Surveying and Assessing Firefighters Fitness and Electrocar-
diogram study drew professional firefighters from 13 firehouses in
a metropolitan area of nearly 300,000 residents. Each firehouse had
approximately 45 firefighters in four platoons that work in extended
rotating shifts schedule, 2-day shifts (10 hours), 2-night shifts (14
hours), followed by four off-duty days.
All professional firefighters were eligible to participate. Re-
cruitment was based on non-probability sampling; however, to min-
imize sampling bias, every possible effort was made to approach all
eligible firefighters until the full sample was obtained. With institu-
tional review board’s approval, the research team composed of the
principal investigator and four research assistants, travelled among
the firehouses and recruited from all platoons. In a quiet, private
room, consent was obtained and six paper-and-pencil surveys were
completed. The surveys were used to assess sleep problems, de-
pressive symptoms, substance use (alcohol, caffeine, and nicotine),
social bonding, and quality of life (physical and mental well-being).
Measures
1. Sleepproblems:thepreviouslyvalidatedPittsburghSleepQuality
Index (PSQI)19and Epworth Sleepiness Scale (ESS)6were used
to subjectively evaluate sleep quality in firefighters. Firefighters
reporting disturbed sleep pattern (PSQI score ≥ 5), decreased
daytime alertness (ESS score >10), or both, were considered
sleep deprived. To objectively evaluate sleep pattern in profes-
sional firefighters, a small cohort completed a sleep diary, and
continuously wore a motionlogger actigraph (Ambulatory Moni-
toring Inc., Ardsley, NY) on their nondominant wrist for 3 days,
during which all activities including fire and medical calls were
monitored. Four objective indices were obtained from the acti-
graph: sleep duration, sleep efficiency, sleep latency, and wake
after sleep onset. Sleep pattern was considered disturbed if the
firefighter had at least two of the following: sleep duration less
than 6 hours, sleep efficiency less than 85%, sleep latency more
than 30 minutes, or wake after sleep onset more than 30 minutes.
2. Depression: the Beck Depression Inventory (BDI-II)20was used
to measure depressive behavior. Beck Depression Inventory, a
21-question multiple-choice survey, is the most widely used self-
reportinventorytoscreenfordepressivesymptoms.The5-minute
inventory includes items related to symptoms of depression in-
cluding hopelessness, irritability, mood, and fatigue. The validity
and reliability of BDI-II has been extensively studied.20Firefight-
ers scoring 14 points or more (possible range 0–63) on the BDI-II
were considered mild-to-moderately depressed.
3. Substance Use (alcohol, caffeine, & nicotine): The Time Line
Follow Back21survey was used to characterize substances use
behaviors. Time Line Follow Back survey uses a calendar to
estimate the daily alcohol, caffeine, and nicotine use over the
past 2 weeks, beginning from the day of recruitment. Working
backward, the firefighters recorded for every day the (1) number
ofalcoholicdrinks(asastandarddrink),(2)numberofcaffeinated
drinks (coffee, cola) consumed (in fluid ounces), and (3) number
of cigarettes, cigars, and/or pipe bowls smoked, and/or dips of
smokeless nicotine (as number of cigarettes). A consumption of
four or more (men) or three or more (women) standard alcoholic
drinks per day was considered a binge drinking behavior, with
those who repeat the binge drinking behavior two or more times
per week (≥eight times per month) were considered hazardous
drinkers. Also, a consumption of 700mg (∼40 ounce coffee) of
caffeine per day was considered caffeine overuse behavior. For
this study, firefighters who reported the use of cigarettes, cigars,
and/or pipe bowls smoked, and/or dips of smokeless nicotine at
least once were considered nicotine users.
4. Social Bonding: a 30-item, 6-subscale survey, Spirituality in
Everyday Life (SEL).22was developed for this study and used
to measure social bonds and connections. Items reflected activ-
ities related to feeling supported by others, thinking about rela-
tionships with others, feeling a sense of belongingness, thinking
about bonds with others, showing support for others, and being
involved with others. A 5-point Likert-type scale (1 = never to
5 = repeatedly) was used to determine the frequency with which
respondents experienced the activity within the past year.
5. Quality of Life (Physical and Mental Well-Being): 12-Item Short
Form Health Survey (SF-12)23was used to evaluate quality of
life in the current study. The 2-minute SF-12 survey is a shorter
version of the SF-36 Health Survey designed to reproduce the
physical and the mental health component summary scores of
the overall subject’s health quality status. The reliability of SF-12
has been previously reported to be adequate (test-retest reliabil-
ity > 0.76).23In this analysis, physical health component and
mental health component scores less than 50% were considered
indicators of poor physical and mental well-beings, respectively.
Statistical Analysis
All values are mean ± standard deviation. The degree of
association between the constructs was determined using Pearson’s
correlation coefficient (r) and partial correlation. Categorical values
were compared using χ2test and z test for proportion differences
to compare the prevalence of high-risk behaviors in different sub-
groups. All statistical analyses were performed using SPSS (Version
17, Statistical Products and Services Solutions Inc, Chicago, IL) and
a P < 0.05 was considered statistically significant.
RESULTS
A convenient sample of 112 professional firefighters (n =
112, 16% of target population) was enrolled from six different fire-
houses from fire department. All firefighters (n = 112, age 43.6
± 7.7 years, 95.5% men, 81% white, 13% African American, 6%
Hispanic) completed the six paper-and-pencil surveys. The sample’s
demographics were similar to that of fire department as a whole. Of
note, the firefighters were experienced with the mean job duration
of firefighting experience 15.5 ± 7.0 years. On self-report, 11.6%
were current smokers (reporting 17 ± 12 cigarettes/day for 10.8 ±
11.0years),11.6%previouslyquitsmoking,and18%werecurrently
receiving medical treatment for cardiac or respiratory conditions (of
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Carey et al JOEMrVolume 53, Number 8, August 2011
Figure 1. Prevalence of psychosocial
characteristics of professional firefight-
ers. Sleep deprivation and binge drink-
ing are the most prevalent followed by
nicotine use and poor mental well-being.
Other high-risk health behaviors were less
prevalent.
note: 9% for hypertension, 5% for dyslipidemia, 5% for sleep apnea,
and 4% for coronary artery disease).
The most prevalent problems were sleep disturbances and
binge drinking (nearly 60%) followed by nicotine use and poor men-
tal well-being (20%). Lower rates were found for depressive symp-
toms,hazardousdrinking,caffeineoveruse,poorphysicalwell-being
and poor social bonding which were less prevalent (Fig. 1).
The Cronbach’s α for the BDI-II survey in the sample was
0.86. Among the 112 firefighters in the sample, 89.2% (n = 100)
reported no depression, 10.8% (n = 12) had some degree of depres-
sion (6.2% mild depression, 3.6% moderate depression, 1% severe
depression), 59% (n = 64) were sleep deprived (PSQI score = 6.02
± 3.08,ESSscore=5.22 ± 2.84),8%hadpoorphysicalwell-being
(n = 9, PHC = 62% ± 13%), 21% had poor mental well-being (n
= 23, mental health component = 56% ± 12%), 80% used alcohol
(1.6 ± 1.7 standard alcoholic drinks per day, range 0.0–9.7), 56%
had binge alcohol drinking behavior, 14% had hazardous drinking
behavior, 20% used nicotine, and 5.4% overused caffeine. In addi-
tion, the overall Cronbach’s α for the newly developed SEL scale
was 0.95. The exploratory factor analysis for SEL showed that the
six subscales explained 72% of the expected variance. The mean
total score for the overall scale was 95 ± 20 (possible range: 30
[worst]–150 [best], observed range: 30–143). Using receiver oper-
ator characteristics curve, a logical cutoff point of 55 (2 SD below
the mean) was selected to identify those with low level of social
bonding. Given that cutoff point, ∼4% of firefighters had low level
of social bonding within the social network of firefighters. Of note,
the lowest mean subscale score (3.3 ± 0.9) was related to feeling a
sense of belongingness, and the highest (4.2 ± 0.95) was related to
feeling supported by others.
Compared with those who were not depressed, depressed fire-
fighters were more likely to be sleep deprived (54% vs 100%, χ2
= 9.48, P = 0.002), and to have hazardous drinking behavior (12%
vs 33%, χ2= 3.98, P = 0.046). On the other hand, firefighters
who were sleep deprived were more likely to report poor physical
well-being when compared with those who were not sleep deprived
(11% vs 0%, P < 0.05 using z test for proportion difference) but not
poor mental-well-being. Those with hazardous drinking behavior
were more likely to report nicotine use (50% vs 15%, χ2= 10.9, P
= 0.001). Interestingly, comparing firefighters with caffeine overuse
behaviortothosewithout,firefighterswithcaffeineoverusebehavior
were more likely to have poor physical (50% vs 7%) and poor men-
tal (66% vs 22%) well-being (P < 0.05 using z test for proportion
difference). Interestingly, those with poor mental well-being were
also more likely to report poor social bonding (13% vs 2%, P < 0.05
using z test for proportion difference).
A zero ordered correlation matrix shows the extent between
the prevalence of the nine constructs: depressive symptoms, sleep
deprivation, binge and hazardous alcohol drinking behaviors, caf-
feine overuse, nicotine use, poor physical and mental well-beings,
and poor social bonding (Table 1). Overall, small-to-medium cor-
relations (0.25–0.35) were identified between sleep deprivation, de-
pressive symptoms, poor physical/mental well-beings, and drinking
behaviors. To avoid misleading correlations between constructs due
to a third causal construct, also known as a “spurious variable,”
partial correlation was used to examine significant correlations.24
All significant correlations in Table 1 remained independent after
controlling for other relevant constructs except depression and haz-
ardous drinking that was insignificant after controlling for sleep de-
privation, nicotine use, or both. There was no relationship between
sleep deprivation and hazardous drinking behavior (controlling for
depression, poor physical well-being, or both); or depression and
poor mental well-being (controlling for sleep deprivation, hazardous
drinking behavior, or both). The distribution of these nine constructs
amongdifferentdemographicsoffirefighters(ie,age,race,sex,years
of experience as a firefighter, presence of obesity, hypertension, and
cardiac history) was only statistically significant in three: age, race,
and hypertension (Table 2).
Sleep Pattern (Actigraph)
While on night duty, a random cohort of firefighters (n = 22)
wore the motion logger actigraph continuously for 72 hours. The
demographics of this cohort were similar to that of the sample and
general firefighters population (age = 42 ± 6 years, 86% men, 82%
white,18%black).Actigraph’sresultsshowedthatsleepdurationwas
6.1 ± 1.8 hours, sleep efficiency 89% ± 10%, sleep onset latency
38 ± 39 minutes, and wake after sleep onset 37 ± 25 minutes.
Approximately, 36% of firefighters (n = 8/22) had a disturbed sleep
pattern; there was no difference in PSQI score between the two
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JOEMrVolume 53, Number 8, August 2011Psychosomatic Well-being of Professional Firefighters
TABLE 1. Correlation Matrix Between Psychosocial Characteristics of Professional Firefighters (n = 112)
Depressive
Symptoms
Sleep
Deprivation
Binge
Drinking
Hazardous
Drinking
Caffeine
Overuse
Nicotine
Use
Poor
Physical
Well-being
Poor
Mental
Well-being
Poor
Social
Bonding
Depressive symptoms
Sleep deprivation
Binge drinking
Hazardous drinking
Caffeine overuse
Nicotine use
Poor physical well-being
Poor mental well-being
Poor social bonding
0.30* –0.06
0.17
0.19**
0.17
0.35*
0.05
0.04
0.08
–0.01
0.05
0.03
0.15
0.31*
–0.02
0.16
0.26*
–0.07
0.08
0.36*
0.12
0.18
0.14
0.02
0.06
0.26*
0.04
0.15
0.09
0.07
0.07
0.06
0.17
0.03
–0.07
0.25*
*P < 0.01; **P < 0.05.
TABLE 2. The Prevalence of Psychosocial Characteristics of Firefighters Among Different Demographics
Prevalence Rate (%)
n
Depressive
Symptoms
Sleep
Deprivation
Binge
Drinking
Hazard
Drinking
Caffeine
Overuse
Nicotine
Use
Poor
Physical
Well-being
Poor
Mental
Well-Being
Poor
Social
Bonding
Age, yrs
≤40
41–47
≥48
White
Black
Others
Male
Female
Yes
No
Yes
No
31
41
40
91
15
6
107
5
46
66
40
72
9.7
19.5*
2.5
9.9
20
0
11.2
0
6.5
13.6
2.5
15.3*
74.2
66.7
38.5*
60.2
60.0
33.3
57.7
80.0
51.1
64.1
53.8
61.4
61.3
61.1
52.5
64.8*
26.7
33.3
57.0
80.0
58.7
57.6
60.0
56.9
12.9
14.6
15.0
15.4
13.3
0
15.0
0
13.0
15.2
20.0
11.1
3.2
4.9
7.5
6.6
0
0
5.6
0
8.7
3.0
2.5
6.9
25.8
19.5
15.0
19.8
13.3
33.3
19.6
20
21.7
18.2
20.0
19.4
11.1
9.4
8.8
10.5
8.3
0
10.0
0
13.5
7.1
8.1
10.7
22.2
28.1
23.5
26.3
25.0
0
23.3
60.0
29.7
21.4
13.5
32.1*
6.5
4.9
0
4.4
0
0
3.7
0
6.5
1.5
5.0
2.8
Race
Sex
Obesitya
Hypertensionb
*P < 0.05.
aBody mass index >30 kg/m2.
bBlood pressure ≥135 (systole) or ≥85 (diastole) mmHg
groups, however, those with disturbed sleep pattern had higher ESS
scores (10.3 ± 4.1 vs 5.9 ± 2.9, P = 0.01).
DISCUSSION
This prospective descriptive study reports that high-risk be-
haviors that impact psychosomatic well-being are prevalent in pro-
fessional firefighters, which require environmental and individual-
based health promotion interventions. Humans are physiologically
programmedtobeawakeduringthedayandsleepatnight.Prolonged
deviation from that pattern may result in adverse effects on perfor-
mance and health. Almost 60% of firefighters in this study met our
acceptable criteria for sleep deprivation. Thirty-eight percent of the
subsample of firefighters that wore the motionlogger actigraph had
also disrupted sleep patterns and reported excessive daytime sleepi-
ness. Individuals differ in their ability to tolerate night work, adjust
to shift work and sleep deprivation. For example, after a single night
of work (acute sleep deprivation), half of the adults meet perfor-
mance expectations, a third demonstrate moderate impairments, and
the remaining individuals have marked decrement in performance.25
A person’s ability to tolerate night work may vary over time, unre-
lated to any identifiable factor. Laboratory experiments on chronic
sleep deprivation have demonstrated that cognitive deficits accumu-
late to severe levels over time without full awareness by the af-
fected individual.26Chronic sleep deprivation reduces the ability
to think clearly, handle complex mental tasks, solve problems, and
form new memories.6Firefighters, most at risk for chronic sleep de-
privation, must be educated about their need for and maximize their
ability to achieve adequate restorative sleep. Identifying workers at
higher risk for coping with extended work shifts, such as those with
undiagnosed sleep disorders (ie, obstructive sleep apnea) is a be-
ginning. In the meantime, a stopgap from the sleep lab involves
educating firefighters about the judicious use of caffeine as a stim-
ulant and a 10-minute nap that can improve subjective sleepiness,
fatigue, vigor, and cognitive performance.27
Research exploring stress and depression among firefighters
has received little attention and is therefore lacking in nursing and
health related literature. As an initial step to increase knowledge
and understanding regarding the mental health care needs of fire-
fighters, it was important to explore stress and depressive symptoms
in this particular population to help health care providers plan and
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Carey et al JOEMrVolume 53, Number 8, August 2011
implement early interventions aimed at preventing adverse phys-
ical and psychosocial health-related events. While the prevalence
of depression and hazardous drinking were relatively low in this
sample, statistically significant correlations were found for depres-
sive symptoms, sleep problems, and hazardous drinking; albeit not
strong correlations (r < 0.60). Importantly, critical firefighter du-
ties may be compromised if firefighters suffer from by even one of
these problems, let alone all three. Alcohol-use disorders are asso-
ciated with depressive episodes, severe anxiety, insomnia, suicide,
and abuse of other drugs; continued heavy alcohol use also shortens
the onset of heart disease, stroke, cancers, and liver cirrhosis, by af-
fecting the cardiovascular, gastrointestinal, and immune systems.28
Identification of this at-risk group of firefighters and intervening to
address these triune problems is critical given the health and safety
consequences.
Firefighters in this study reported higher rates of alcohol use
compared with what has been previously described in the literature
(80% used alcohol with average of > 10 drinks/wk compared with
only 62% with average ∼5 drinks/wk).29For most adults, moderate
alcohol (up to two drinks per day for men and one drink per day for
women) causes few problems, yet drinking in any amount may be
contraindicated for engaging in activities that require alertness and
skill (such as firefighting). There is evidence that regular moderate
drinking reduces performance and reaction time, with the potential
to increase accident risk and desynchronize circadian rhythms.30In
addition, the comorbid use of cigarettes and alcohol also constitutes
serious health risks. In this study, 17.7% reported that they currently
smoked an average of 1.06 packs per day. Interestingly, there was
a discrepancy on how many firefighters self reported as smokers
(11.4%) versus reporting smoking a cigarette over the 2 weeks in
the Time Line Follow Back survey (20%). In other words, although
some firefighters actually did smoke cigarettes, they did not self
identify as smokers,a phenomenon that reflects improper perception
of high-risk health behaviors which demonstrate the appropriateness
of education and awareness in this population.
Despite the need for further psychometric testing, the results
from the initial administration of the SEL are promising. The SEL
assessed how frequently firefighters engaged in activities related to
feeling supported by others, thinking about relationships with oth-
ers, feeling a sense of belongingness, thinking about bonds with
others, showing support for others, and being involved with others.
The large proportion of the sample (96%) with high scores for social
bonding supports the concept of brotherhood among firefighters.17
The US military has recognized that a soldier’s spiritual fitness is a
crucial element in the total force fitness of service members.31As
with firefighters, the solidarity of the military platoon is essential
for the safety and welfare of fellow soldiers. It is important to note
that among the firefighters who participated in this study, feeling
a low level of social bonding and connection was correlated with
poor mental well-being. These findings suggest that social bonding,
belongingness, and connection may impact firefighter’s physical and
mental well-being and overall quality of life. Qualitative research is
lacking regarding how firefighters define brotherhood, sense of be-
longing,andconnection,andhowtheseprinciplescanpromotephys-
ical, mental, emotional, and social well-being among professional
firefighters. Firefighters with poor mental well-being and poor social
bonding deserve particular attention as they may place themselves
and others at risk in the line of duty. Educational programs should
be provided for fire departments to assist them in identifying signs
of mental distress and distancing from the social bonds of the broth-
erhood.
CONCLUSION
This study adds to the understanding of the prevalence of
modifiable risk factors among an urban brotherhood of firefighters.
High-risk health behaviors that impact psychosomatic well-being
are prevalent in professional firefighters, which require environmen-
tal and individual-based health promotion interventions. The inter-
correlationrelationshipsbetweensuchbehaviorsneedtobeexplored
in further details. Sleep patterns are disrupted probably because of
thedurationoftheshiftsandunpredictabilityoftheemergencycalls.
Substance use, whether alcohol, nicotine, or caffeine may provide
relief from the physical and mental demands of the job, or may be
an acceptable norm of the social bonding. Finally, little has been
studied regarding the significance of brotherhood among firefighters
as it relates to social bonding and connection. Building on the possi-
bilitythatsocialbondingmaybeaprotectivefactor,healthpromotion
and intervention programs could be implemented to help fire depart-
ments take a more active role in helping firefighters improve their
health.
ACKNOWLEDGMENT
This study has been supported by a grant from the National
Institutes of Health, R21 NR-011077 (MGC).
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