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ORIGINAL RESEARCH
published: 09 June 2022
doi: 10.3389/frhs.2022.848138
Frontiers in Health Services | www.frontiersin.org 1June 2022 | Volume 2 | Article 848138
Edited by:
Natalie Mota,
University of Manitoba, Canada
Reviewed by:
Rachel A. Hoopsick,
University of Illinois at
Urbana-Champaign, United States
Masahito Fushimi,
Akita University, Japan
*Correspondence:
Andrew J. Smith
andrew.j.smith-2@dartmouth.edu
Scott A. Langenecker
s.langenecker@hsc.utah.edu
Specialty section:
This article was submitted to
Mental Health Services,
a section of the journal
Frontiers in Health Services
Received: 04 January 2022
Accepted: 31 March 2022
Published: 09 June 2022
Citation:
Wright HM, Fuessel-Hermann D,
Lee S, Ridge B, Kim JU, Konopacki K,
Hilton L, Greensides M,
Langenecker SA and Smith AJ (2022)
Preventative Care in First Responder
Mental Health: Focusing on Access
and Utilization via Stepped Telehealth
Care. Front. Health Serv. 2:848138.
doi: 10.3389/frhs.2022.848138
Preventative Care in First Responder
Mental Health: Focusing on Access
and Utilization via Stepped Telehealth
Care
Hannah M. Wright 1, Dianna Fuessel-Hermann 2, Somi Lee 1, Brook Ridge 1,
Joseph U. Kim 1,2 , Kelly Konopacki 1, Layne Hilton 3, Michael Greensides 3,
Scott A. Langenecker 1
*and Andrew J. Smith 1,4,5
*
1Department of Psychiatry, University of Utah School of Medicine, Huntsman Mental Health Institute, Salt Lake City, UT,
United States, 2Salt Lake City Veterans Affairs (VA) Medical Center, Salt Lake City, UT, United States, 3United Fire Authority,
Salt Lake City, UT, United States, 4Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, NH,
United States, 5Lyda Hill Institute for Human Resilience, University of Colorado, Colorado Springs, CO, United States
First responders are at high risk for disorders that arise from repeat exposure to stress
and trauma (Post Traumatic Stress Disorder, depression, and problematic alcohol use).
Although mental health treatments are available, first responders often do not access
them, anchored by barriers that include: lack of knowledge, stigma, negative experience
with mental health providers, and time-based burdens. In this study, we designed an
intervention to address these barriers, extending a Planned-Action framework. Step 1
involved self-report screening for four mental health risks (PTSD, depression, anxiety,
and alcohol use risk), delivered to all personnel electronically, who were free to either
consent and participate or opt-out. The detection of risk(s) in Step 1 led to scheduling
a Step 2 telehealth appointment with a trained clinician. We report descriptive statistics
for participation/attrition/utilization in Steps 1 and 2, rates of risk on four mental health
variables, and rate of adherence to follow-up treatment recommendations. Step 1: In
total, 53.3% of personnel [229 of 429 full-time employees (221 males; eight females; 95%
White; 48% paramedic or Emergency Medical Technician; 25% captain; 19% engineer;
7% other)] initially opted-in by consenting and completing the brief remote screening
survey. Among those who opted-in and completed (n=229), 43% screened positive
for one or more of the following mental health risks: PTSD (7.9%); depression (9.6%);
anxiety (13.5%); alcohol use (36.7%). Step 2: A maximum of three attempts were made
to schedule “at risk” individuals into Step 2 (n=99). Among the 99 who demonstrated
a need for mental health treatment (by screening positive for one or more risk), 56
(56.6%) engaged in the telehealth appointment. Of the 56 who participated in Step 2
clinical appointments, 38 were recommended for further intervention (16.6% of full-time
personnel who participated). Among the 38 firefighters who were recommended to
seek further mental health services, 29 were adherent/followed through (76.3% of those
who received recommendations for further services). Taken together, evidence-based,
Wright et al. Preventative Care in First Responders
culturally conscious, stepped care models delivered via the virtual/telehealth medium
can promote access, utilization, and cost-effective mental health services for first
responders. Implications are for informing larger, more rigorous dissemination and
implementation efforts.
Keywords: occupational stress, utilization, preventative medicine, first responders, PTSD, depression, alcohol,
stepped care
INTRODUCTION
Serving as a firefighter involves chronic stress and trauma
exposures incurred during occupational events such as structure
fires, wildfires, traffic accidents, suicides, drug overdoses, Sudden
Infant Death Syndrome, domestic violence scenes, and disasters.
Firefighters work long hours under shift work schedule demands
and mandatory staffing, prompting deterioration of natural
coping resources [e.g., social supports, restorative sleep; (1–4)].
Chronic physical and psychological stress exposures, paired with
degradation of natural coping processes, leaves firefighters at
risk for physical and mental health problems [e.g., (5–14)]. A
recent study showed that more than 50% of firefighters may
be at risk for PTSD, depression, anxiety, and/or alcohol use
disorder (15). This is a population in need of culturally tailored,
preventative, accessible treatment resources to facilitate mental
health and wellbeing.
Evidence-based treatments are available for the common types
of mental health problems that first responders are at risk for,
including treatments for PTSD (Prolonged Exposure, Cognitive
Processing, Eye Movement Desensitization and Reprocessing)
and depression (Cognitive Behavioral Therapy Treatment
approaches) (16–21). Notwithstanding the efficacy of evidence-
based mental health treatments [e.g., see (22)], fewer than half of
first responders in need of mental health care seek treatment (23).
A recent survey of nearly 40,000 firefighters revealed that among
firefighters with a probable PTSD diagnosis, fewer than 10% had
sought treatment in the past month (24).
Reasons for not seeking mental health treatments are
undoubtedly complex. For example, emergency responder
cultures value archetypes of self-reliance, self-sufficiency, playing
heroic roles, and saving other people at risk to the self
(25). Firefighters are often unaware of the potential mental
health risks for long-term effects of persistent stress (26),
and/or lack the knowledge for where and how to access
mental health providers trained in evidence-based approaches
(27). Among firefighters who are identified as needing mental
health services, seeking such services can be blocked by
stigma and fear of negative professional consequences, losses
of standing, promotion potential, and/or pay (10,26,28).
Additionally, practical barriers exist for being able to attend
health appointments consistently due to shift work, mandatory
staffing practices, and associated time constraints (24,27).
A recent community-based study identified four critical
facilitators for improving mental health service use among first
responders: increasing knowledge, reducing stigma, increasing
positive experience with mental health providers, and removing
time-based burdens (27). This study by Jones et al. (27) addressed
initial steps in a Planned-Action based framework for translating
research into mental health care practice for first responders
having (step 1) identified the problem (i.e., first responders
underutilizing mental health care), (steps 2 and 3) reviewed the
evidence and adaptee toward innovation, and (step 4) assessed
barriers to uptake [see (29,30)]. The first responder community
would benefit from interventions that translate this knowledge
into practice.
In the current study, we sought to extend the next three
steps in a Planned-Action framework by (a) developing
an intervention that applies/translates known barriers and
facilitators (27), (b) implementing the intervention, and
(c) evaluating uptake and utilization (29,30). Within the
Planned-Action framework, we incorporated a rational stepped
care design feature to optimize for cost-effectiveness, future
scalability, and increased access in a scarce resource context
(31–38). The overarching goal of the current manuscript is
to describe the intervention development, implementation,
and utilization process as a means to improve first responder
mental health.
MATERIALS AND METHODS
Design and Setting
The University of Utah Institutional Review Board approved
all study procedures before the initiation of the intervention.
Attempts were made to contact all full-time personnel (with no
exclusions) in a fire department in the Rocky Mountain West
(n=429) to participate in this intervention. An administrator
at the first responder agency provided the clinical team with a
personnel list including names and contact information for every
first responder in the department. The clinical team generated
a unique, secure survey link associated with each member of
the department (generated using REDCap), and the list of first
responder names and unique survey links (containing access to
the Step 1 intervention survey described below) was provided
back to the mental health liaison at the first responder agency.
The agency liaison sent the unique Step 1 survey links via text
message, a participation maximizing effort, that the survey link
be received from “within tribe” (i.e., from a member of the
first responder department). Once they received the survey link,
participation required agreeing to informed consent. Informed
consent provided information about the aim of the survey, data
collection and storage procedures, as well as potential risks and
benefits of participation (e.g., feedback about wellbeing, access
to mental health professionals, consultation). When agreeing
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Wright et al. Preventative Care in First Responders
FIGURE 1 | Participation in each step.
to informed consent, participants were agreeing that if they
screened positive for any mental health risk, they would be
contacted by a scheduling assistant from the clinical team
to schedule an appointment with a mental health provider.
Individuals who agreed/consented were directed to a brief battery
of screening questions (completion time ∼1 min). Individuals
who declined consent were provided a list of mental health
resources and discontinued from participation. Further details of
the intervention are described below.
A total of 229 individuals (roughly 53% of the department)
participated (96.5% male, 95.2% White, mean age =42.28 [SD =
9.64]), including paramedics (47.8%), captains (24.6%), engineers
or drivers (19.3%), chiefs (5.3%), administration (2.2%), or other
(0.9%). The current sample is comparable to national firefighter
demographics (39). See Figure 1 for a summary of participation
by each step in the model.
Overview of Development and Pilot
Implementation
Improving mental health treatment access and utilization has
been the focus of dissemination and implementation science for
several decades (40). Whereas, some barriers and facilitators to
treatment are universal (e.g., availability of trained providers),
others are specific to populations [see (27)]. We sought to develop
an intervention that would improve access and utilization by
addressing first responder specific barriers and facilitators to
mental health services. To do so, we used a Process-Based
framework [i.e., Planned-Action; (29,30)] to extend the evidence
elucidated by Jones et al. (27). As such, our intervention design
choices were as follows:
(1) Maximize flexibility and reduce time-based
burdens/constraints by (a) using a brief risk screening
instrument that reduces participant burden and (b) offering
appointments via virtual telehealth that allowed for first
responders to schedule at their convenience.
(2) Reduce stigma by (a) delivering this as an intervention
that first responders in the participating agency could
“opt out” of and (b) communicate/conceptualize mental
health distress through an occupational stress/performance
enhancement framework.
(3) Increase knowledge by incorporating mental health
education and introducing skills aimed at enhancing
mental health.
(4) Increase positive experiences with mental health providers
by (a) training providers on first responder language
and culture and (b) communicating/conceptualizing mental
health distress through a culturally palatable (i.e., in
first responder cultures) occupational stress/performance
enhancement framework.
Additionally, we addressed rational considerations for cost and
efficiency of distributing therapeutic resources within healthcare
systems using a stepped care design (32–34,36,37). Stepped care
involves providing treatment to patients in the least restrictive
setting while continuously monitoring the effectiveness of each
“step” in the treatment model (31). Moreover, stepped care
models may have complimentary value for improving access
by tailoring the treatment amount and type to the level of
care needed (31,38) which in turn optimizes the financial and
time cost to both patient and clinician (38) and allows for
efficiency of utilizing scarce resources (35). Finally, a stepped care
approach has scalability implications by aiming to operationalize
a set of reproducible, standardized procedures (37,41), often
complemented by the use of technology (42).
Step 1
All 429 personnel received a text message including a secure
survey link unique to that person from a mental health liaison
in their organization. Upon agreeing to informed consent,
individuals completed a self-report questionnaire (completion
length ∼1 min) comprised of 19 questions: six demographic
questions [gender, race/ethnicity, career length, recruit/new hire
status (yes/no), and primary occupational role]; and 13 questions
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Wright et al. Preventative Care in First Responders
screening for trauma history and symptoms of traumatic
stress, depression, anxiety, and alcohol use. Participants who
declined informed consent were provided with a list of mental
health service contacts for therapy and/or crisis services and
discontinued from the intervention. Engagement with the survey
was monitored by the clinical team, and if participants did not
engage [i.e., did not open the survey or complete consent (either
agree or disagree)], up to three attempts were made to contact
them before discontinuing them in the program.
Following completion of the Step 1 screening survey,
participants who screened as “positive” on one or more of
the measures (traumatic stress, depression, anxiety, alcohol
use) were contacted within 48–72 h. Participants who screened
positive for mental health risk(s) and who were contacted
successfully were offered the opportunity to have a 60-
min appointment with a mental health professional (Step
2). Notably, some participants screened positive for mental
health risks and were successfully contacted in attempts to
schedule for Step 2 virtual clinical appointment, but chose
to decline continued participation in the service. Individuals
who did not screen positive for a mental health risk received
a text message indicating that no risk was identified at this
time and were provided with contacts for mental health
services and crisis services should such a mental health need
exist nonetheless.
Step 1 Measures
Traumatic Stress Symptoms
Traumatic stress was assessed with an adapted version of the
Primary Care PTSD Screen for DSM-5 [PC-PTSD-5; (43)]
consisting of five questions used to reflect the Likert scale
associated with the PCL-5 [0 =not at all, 1 =a little bit, 2 =
moderately, 3 =quite a bit, 4 =extremely; see (44–46)]. The
five items were summed together to obtain a continuous total
score (range =0–20) with of 10 or above indicating at risk.
Internal consistency was high for this sample (Chronbach’s α
=0.85).
Depression
The Patient Health Questionnaire-2 [PHQ-2; (47)] is a brief
depression screener consisting of two items answered on a 4-
point Likert scale (0 =not at all to 3 =nearly every day). Items
were summed with a total continuous score of 3 or above used
to indicate risk (47). Internal consistency was adequate for this
sample (Chronbach’s α=0.81).
Anxiety
The Generalized Anxiety Disorder Scale-2 (48) is a brief two-item
screener of anxiety symptoms answered on a 4-point Likert scale
(0 =not at all to 3 =nearly every day). Items were summed with a
total continuous score of 3 or above used to indicate risk. Internal
consistency was low for this sample (Chronbach’s α=0.50).
Alcohol Use
The Alcohol Use Disorders Identification Test-Consumption
Questions [AUDIT-C; (49)] contains three items measuring
alcohol use frequency and quantity. Items were summed with a
total score of 4 for men and 3 for women indicating risk. Internal
consistency was adequate for this sample (Chronbach’s α=0.70).
Step 2
Before engagement in the virtual clinical interview (Step 2),
participants who screened positive in Step 1 and agreed to
schedule a Step 2 appointment were sent a new survey link,
which was automated to be sent 1 h before the appointment with
instructions to complete prior to the interview. The Step 2 survey
represented an expanded version of Step 1 with a focus on more
in-depth, reliable measures of PTSD (PCL-5; Weathers et al.,
2012) and depression [PHQ-9; (50)] to provide clinicians with
more clinically actionable information (e.g., which dimensions
of PTSD and mood were most clinically prominent). During
the scheduled appointment participants engaged in a 60-min
clinical interview with a mental health provider (psychologists or
licensed clinical social workers) comprised of four aspects.
(1) Psychosocial and functional assessment (∼30 min).
(2) Interactive education about the relationship between chronic
stress and mental/physical health tailored to the problems
identified in the assessment (∼15 min).
(3) Introduction of a brief problem-focused coping
skill (∼10 min).
(4) Recommendation/referral. After the clinical interview
possible referrals were made as follows: (a) trauma/PTSD
focused therapy; (b) brief neurocognitive screening (Step 3 in
the intervention); (c) medication evaluation; (d) behavioral
health interventions; (e) other types of therapies, (f ) general
stress-focused therapy via Employee Assistance Program; and
(g) no further recommendations. A combination of referrals
was possible for any given patient.
Step 2 Measures
Traumatic Stress Symptoms
The PTSD Checklist for DSM-5 (PCL-5; Weathers et al., 2012)
contains 20 self-report items answered on a 5-point Likert scale
(1 =not at all to 5 =extremely) measuring probable stress-
related disorders. Items were summed with a total score of 33 or
above used to indicate risk (44). Participants were not required
to endorse a Criterion A trigger prior to completing the PCL-
5. Internal consistency was high for this sample (Chronbach’s
α=0.95).
Depression
The Patient Health Questionnaire-9 [PHQ-9; (50)] is a 9-item
self-report instrument answered on a 4-point Likert scale (0 =
not at all to 3 =nearly everyday) for depression. A total score of
10 corresponding to “moderate” depressive symptoms was used
to indicate risk. Internal consistency was high for this sample
(Chronbach’s α=0.90).
RESULTS
Step 1
At Step 1, ∼43% of respondents screened positive for at least
one identified risk (72 participants screened positive for one risk;
15 participants, two risks; eight participants, three risks; four
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Wright et al. Preventative Care in First Responders
TABLE 1 | Number of identified risks at step 1.
Number of identified risks Percentage
1 identified risk 72.7% (72)
2 identified risks 15.2% (15)
3 identified risks 8.1% (8)
4 identified risks 4.0% (4)
TABLE 2 | Probable diagnostic rates at step 1.
Diagnostic risk Percentage
PTSD 7.9% (18)
Depression 9.6% (22)
Anxiety 13.5% (31)
Problematic alcohol use 36.7% (84)
TABLE 3 | Probably diagnotic rates at step 2.
Diagnostic risk Percentage
PTSD 25.0% (14)
Depression 17.9% (10)
TABLE 4 | Recommendations and follow up.
Recommendation Percentage
Occupational trauma therapy
only
25% (14)
Step 3 brain health screen 5.36% (3)
Health behavioral intervention 3.57% (2)
Other therapy 3.57% (2)
Maintain employee assistance
program
1.79% (1)
Combination of referrals (e.g.,
occupational trauma therapy and
step 3)
42.1% (16)
participants, four risks). See Table 1. Probable diagnostic risk
rates were shown at the following distributions: PTSD (7.9%),
depression (9.6%), anxiety (13.5%), and problematic alcohol use
(36.7%), see Table 2. Individuals who screened positive for any
risk (n=99) were referred to Step 2.
Step 2
Of the 99 who screened positive and with attempts to contact
them, 56 engaged in the virtual telehealth appointment. Among
the 56 individuals who participated in Step 2, 17.9% were above
the cutoff for probable stress-related disorders while 25% were
identified as having moderate to severe levels of depression,
see Table 3. Of the 56 who participated in Step 2, 67.86% (n
=38) were recommended to pursue additional mental health
services beyond Step 2, which is equivalent to ∼17% of full-
time personnel who engaged in this intervention (denominator
=229). See Table 4 for the percentage of referrals by the level
of care. Among the 38 individuals who participated in Step 2
and received a recommendation for follow up 76.32% (n=29)
adhered to these recommendations.
DISCUSSION
Ample evidence suggests that first responders are difficult
to engage in mental health resources. Despite longstanding
knowledge of mental health risks are incurred among firefighters
as an occupational hazard, there is limited applied research and
behavior service delivery that focuses on improving access and
utilizization (27,51). The goal of the present study was to describe
an applied intervention aimed at decreasing barriers to access and
promoting the utilization of services among firefighters.
In summary, we utilized a combined approach, applying
barriers and facilitators identified by Jones et al. (27) into an
intervention, thereby extending a Planned-Action framework.
Specifically, Jones and colleagues identified these prime
facilitators of mental health service utilization among first
responders: increasing knowledge, reducing stigma, increasing
positive experience with mental health providers, and removing
time-based burdens. We intentionally targeted each of these
factors (e.g., flexible scheduling using a telehealth platform;
stigma reduction using an “opt-out” strategy and a normalizing
“performance enhancement” focus [rather than a pathology
orientation]; increase positive experience by providing cultural
training for providers). Additionally, we implemented the
intervention using a cost-conscious and utilization-boosting
stepped care implementation design [see (52)].
Our findings show that the current intervention was
engaged by ∼56% of “at-risk firefighters.” More than
half of those who screened positive and engaged in a
telehealth visit were provided with recommendations
for further mental health service follow-up (n=38),
among whom 76% (n=29) followed through with these
referrals. This is comparable to 62% recommendation
adherence in other samples [e.g., (52)]. Our high level of
adherence to follow-up recommendations suggests that low-
intensity intervention such as the one presented is useful in
promoting needed, preventative mental health service use
among firefighters.
First responders are often thought of as individuals who move
toward crises to come to the aid of others. This intervention
mirrored that sentiment by “moving toward” first responders and
meeting them where they are. The clinical scheduling assistant
reached out to participants within 48–72 h after screening
positive for risk. Prioritizing individualized communication
likely increased participation with the stepped care intervention.
Step 2 appointments were provided virtually, making it more
feasible for participants to attend. It has been well-noted that
aside from stigma-related barriers, structural barriers (53) often
hinder first responders from engaging with mental health
professionals. It is possible that follow through with the Step 2
session was boosted by the easily accessible format in this stepped
care intervention.
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Wright et al. Preventative Care in First Responders
It is also important to note that the number of firefighters
who were referred for more than one clinical session was only
∼17% of the total number who participated in this intervention
(denominator =229). This finding indicates the preliminary
value in an approach such as ours for “right sizing” resource
appropriations needed to provide substantive mental health
services, although much work is yet to be done to further
elucidate that cost/funding need across time (and to generalize
beyond one fire department).
This study was limited by several factors. First, this
intervention was implemented in a single fire department thus
limiting the generalizability of findings to other departments.
Further research needs to take this intervention system to
multiple fire departments to increase power as well as account
for potential differences in various stations. Second, this project
addressed firefighters but no other first responder populations
such as police officers, emergency medical technicians (EMTs),
and emergency dispatch. To evaluate its effectiveness in other
first responder fields this system needs to be tested in a variety of
emergency service stations as well as among adequate numbers of
first responders. Third, insufficient sleep was not measured in this
sample in the Step 1 screening tool. It has been widely established
that sleep problems are common among emergency personnel
(54) due to several factors such as disruptions of circadian
rhythm and exposure to occupational trauma (55). Examination
of insufficient sleep should perhaps be included in any initiation
of stepped care services, thus increasing opportunities to
provide psychoeducation as well as individualized referrals to
improve sleep. Fourth, funding constraints limited our ability
to engage participants in qualitative interviews about their
experience with the intervention. This is a critically missing
component for future research to endeavor to maximally
shape interventions to be effective across cultures. Fifth, some
individuals who screened as “at-risk” chose not to participate
in Step 2, and data on discontinuation was not gathered,
such as reasons for discontinuing despite being identified
with a mental health service need is an important next step.
Future studies should aim to examine the reasons for declining
participation to better serve this population. Sixth, we do not
have comprehensive follow-up data on either the efficacy of the
brief problem-focused interventions administered or the longer-
term efficacy of engaging in this intervention. It is important
for future studies with sufficient funding to pursue the value
of such brief intervention approaches. Established dissemination
and implementation frameworks [e.g., the Planned-Action
framework; (29); see (30)] are built to provide a rigorous and
larger-scale study of interventions such as this. Such work
would help to improve and expand these promising preliminary
findings, to promote high quality and best practices to help draw
in the largest proportion of “in need” first responders.
While the research on mental health outcomes for first
responders is limited, what does exist indicates that this
group is at significant risk for psychiatric conditions and
that they are hesitant to seek help. However, such hesitancy
to seek help, whether it be due to stigma or barriers to
access, should not be equated with disinterest in receiving
help when needed or offered. The results of this project
are encouraging as it shows that by providing appropriate
and tailored levels of care, firefighters can be open to
receiving mental health referrals and will engage with
said referrals. The work of a first responder has always
presented numerous challenges that increase the risk of
psychopathology. But with the ever-increasing number of
natural disasters, social unrest, and the ongoing COVID 19
pandemic, finding ways to increase access to mental health
resources and decrease the stigma among those services is
more important than ever. Much work remains to be done
to evaluate the effectiveness of mental health treatment in
this population.
DATA AVAILABILITY STATEMENT
The data presented in this article is not readily available given the
nature of this research, participants of this study did not agree
for their data to be shared publicly. Requests to access the data
should be directed to aj.smith-2@dartmouth.edu.
ETHICS STATEMENT
The studies involving human participants were reviewed and
approved by University of Utah IRB. The patients/participants
provided their written informed consent to participate in
this study.
AUTHOR CONTRIBUTIONS
HW and DFH wrote the manuscript. All authors contributed to
the article and approved the submitted version.
FUNDING
Program Description Issued By US Department of Homeland
Security (DHS), Federal Emergency Management Agency
(FEMA)/Grant Programs Directorate (GPD), Catalog of Federal
Domestic Assistance (CFDA) Number 97.044, CFDA Title
Assistance to Firefighters Grants (AFG), Notice of Funding
Opportunity Title FY 2018, Assistance to Firefighters Grants,
Notice of Funding Opportunity Number DHS-18-GPD-044-00-
99, Authorizing Authority for Program Section 33 of the Federal
Fire Prevention and Control Act of 1974, Pub. L. No. 93-498,
as amended (15 U.S.C § 2229), Appropriation Authority for
Program Department of Homeland Security Appropriations Act,
2018 (Pub. L. No. 115-141), and Program Type New Grant
ID: EMW-2018-FO-05385.
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Wright et al. Preventative Care in First Responders
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0019
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