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Initial and continuing physical and behavioral health and wellness education in the fire service: an innovation study on heart attack, suicide, and cancer prevention for Howard County Fire and Rescue

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Initial and continuing physical and behavioral health and wellness education in the fire service: an innovation study on heart attack, suicide, and cancer prevention for Howard County Fire and Rescue

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Content Running head: HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 1

INITIAL AND CONTINUING PHYSICAL AND BEHAVIORAL HEALTH AND
WELLNESS EDUCATION IN THE FIRE SERVICE: AN INNOVATION STUDY ON
HEART ATTACK, SUICIDE, AND CANCER PREVENTION FOR HOWARD COUNTY
FIRE AND RESCUE
by
Gamaliel Baer
______________________________________________________________________________
A Dissertation Presented to the
FACULTY OF THE USC ROSSIER SCHOOL OF EDUCATION
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the
Requirements for the Degree
DOCTOR OF EDUCATION
May 2019
Copyright 2019 Gamaliel Baer

HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 2

Acknowledgements
“Listen to many, speak to few,” said Shakespeare. I have listened and learned from many
and have many people to thank. The fire service has positively impacted my life in countless
ways, and I am grateful to be a part of it. Without the fire service, I most likely would not have
gone to Johns Hopkins for my masters, served as a Coast Guard Reservist, or gone to University
of Southern California. Howard County Fire and Rescue has been a continuous educational
experience that I am grateful for and vow to pay forward. Thank you to the instructors from
Training Class 24 who shaped me into a more ready, resilient, and respectable human being. To
my brothers and sisters from Class 24, thank you for what you continue to do for the citizens and
guests of Howard County, for Maryland, and for the United States. To the officers that I have
worked for, thank you for keeping me safe, and investing in me. To Chief Baker, you led the best
shift I was ever a part of. Thank you for letting me be a part of the development program for
Special Operations. To Chief Butler, thank you for your support in my fire department career,
my time as a Coast Guard Reservist, and for my return to school. To Chief Rund, thank you for
your mentorship, for inviting me onto your team, and for your support during my time back in
school.
Children are a gift and a continuous source of learning and growth. Thank you, Gianna
and Abram for the fun times we shared while I was in school. Thank you for making me smile.
Thank you for supporting me when I needed to study. Thank you for helping Mommy when I
could not. You are both very special, and I am proud of you. You will be great older siblings. I
love you both.
Eternal truths are hard to come by. However, I have come to appreciate many of the
truths that Aristotle teaches from Dr. Dreisbach. “The roots of education are bitter, but the fruit is
sweet.” To Dr. Harnett, thank you for the lessons of eternal value on taking care of ourselves
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 3

physically and mentally. To Dr. Canny, Dr. Datta, and Dr. Seli, thank you for your guidance and
support in helping me to understand the eternally valuable KMO framework.
Father and Mother Baer, thank you for your love. Thank you for helping with the kids
when I needed to study. Thank you for the encouragement, ideas, and feedback. Thank you for
the family meals and events that you prepared. Thank you for the investment into my siblings
and me. To my siblings, thank you for your support and for the inspiring lives that you all live.
Eternally grateful for my friends, old and new that have helped to shape who I am. To my
friends in the fire service, public safety, the armed services, the foreign service, and the
intelligence services, thank you for what you do for the world, the U.S., Maryland, Howard
County, and for me. To my friends and professors from University of Maryland, Johns Hopkins,
and University of Southern California, thank you for the education, debate, friendship and
guidance. To my friends in the health and wellness field on the research side and the practitioner
side, thank you for your investment in humanity. To my friends from Howard County, thank you
for the “village” that you are a part of that it takes to raise children.
One person that I could not have done this without is my wife Nan. Nan, thank you for
sharing this life with me. Thank you for supporting me on this three-year adventure. I could not
have done this without you. Our family is my inspiration, and we have built a home that I am
proud of and grateful for. You sacrificed many nights while I studied, and supported me
physically, mentally, and spiritually. I am excited to be done and to have more time with you,
Gianna, Abram, and our newest addition. What a great graduation gift!

HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 4

Table of Contents
Chapter One: Introduction ........................................................................................................ 11
Organizational Context and Mission ................................................................................ 11
Organizational Performance Need .................................................................................... 12
Related Literature.............................................................................................................. 13
Importance of the Organizational Innovation ................................................................... 14
Organizational Performance Goal ..................................................................................... 15
Description of Stakeholder Groups ................................................................................... 16
Stakeholder Groups’ Performance Goals.......................................................................... 17
Stakeholder Group for the Study ...................................................................................... 17
Purpose of the Project and Questions ............................................................................... 18
Methodological Framework .............................................................................................. 19
Definitions......................................................................................................................... 20
Organization of the Study ................................................................................................. 21
Chapter Two: Review of the Literature.................................................................................... 22
Health and Wellness in the Fire Service at the National Level ........................................ 23
Firefighter Fatality Trends ................................................................................................ 23
A changing fire service ......................................................................................... 23
Heart attack ........................................................................................................... 24
Suicide................................................................................................................... 28
Cancer ................................................................................................................... 31
A research-based framework for heart attack, suicide, and cancer education. ................. 35
Industry and Government Recommendations and Initiatives ........................................... 36
The International Association of Fire Fighters (IAFF) ......................................... 37
Non-governmental organizations .......................................................................... 39
The U.S. Federal Government .............................................................................. 41
Fire Service Culture .......................................................................................................... 43
Health and Wellness in the Fire Service at the State Level .............................................. 46
Finding a Minimum Standard ............................................................................... 47
Review of Regional Fire Service Course Offerings ............................................. 48
State Fire Training Example ................................................................................. 49
Health and Wellness in the Fire Service at the Local Level: Howard County, MD ......... 51
Organizational Structure ................................................................................................... 51
Initial education .................................................................................................... 51
Continuing education ............................................................................................ 52
Bureau of Occupational Safety and Health ........................................................... 52
Organizational Standards .................................................................................................. 52
Promotional process .............................................................................................. 52
Annual evaluations................................................................................................ 53
Day-to-day expectations ....................................................................................... 53
Organizational Support ..................................................................................................... 53
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 5

BOSH Knowledge, Motivation, and Organizational Influences ...................................... 55
Knowledge and Skills’ Influences .................................................................................... 55
Knowledge types ................................................................................................... 57
Content knowledge for health and wellness ......................................................... 57
Pedagogical knowledge for health and wellness .................................................. 59
Motivation Influences ....................................................................................................... 62
Motivation ............................................................................................................. 62
Utility value theory ............................................................................................... 63
Attribution theory.................................................................................................. 65
BOSH attributions for firefighter health and wellness ......................................... 66
Organizational Influences ................................................................................................. 68
Conceptual Framework: The Interaction of BOSH’s Knowledge and Motivation and the
Organizational Context ..................................................................................................... 72
Conclusion ........................................................................................................................ 78
Chapter Three: Methods ............................................................................................................ 79
Participating Stakeholders ................................................................................................ 80
Interview Criteria and Rationale ....................................................................................... 81
Criterion 1 ............................................................................................................. 81
Criterion 2 ............................................................................................................. 81
Criterion 3 ............................................................................................................. 81
Interview and Survey Sampling (Recruitment) Strategy and Rationale ........................... 81
Document Analysis Sampling Criteria and Rationale ...................................................... 83
Criterion 1 ............................................................................................................. 83
Criterion 2 ............................................................................................................. 83
Criterion 3 ............................................................................................................. 83
Document analysis Sampling (Access) Strategy and Rationale ....................................... 83
Explanation for Choices ........................................................................................ 84
Qualitative Data Collection and Instrumentation ............................................................. 84
Interviews .............................................................................................................. 84
Documents and Artifacts....................................................................................... 85
Data Analysis .................................................................................................................... 86
Credibility and Trustworthiness ........................................................................................ 87
Quantitative Data Collection and Instrumentation ........................................................... 88
Surveys .................................................................................................................. 88
Validity and Reliability ..................................................................................................... 89
Ethics................................................................................................................................. 90
Limitations and Delimitations ........................................................................................... 92
Chapter Four: Results and Findings ......................................................................................... 94
Results and Findings for Knowledge Influences .............................................................. 96
Knowledge of Physical and Behavioral Health and Wellness Concepts .......................... 97
Document analysis ................................................................................................ 98
Survey data.......................................................................................................... 100
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 6

Interview data...................................................................................................... 102
Knowledge of Effective Pedagogical Processes ............................................................. 105
Document analysis .............................................................................................. 105
Survey data.......................................................................................................... 107
Interview data...................................................................................................... 108
Synthesis of Knowledge Findings .................................................................................. 111
Results and Findings for Motivation Influences ............................................................. 112
A High Degree of Value in Educating Firefighters on Health and Wellness ................. 113
Survey data.......................................................................................................... 116
Interview data...................................................................................................... 118
Firefighter Health and Wellness Can be Changed through BOSH’s Efforts .................. 121
Survey data.......................................................................................................... 123
Interview data...................................................................................................... 124
Synthesis of Motivation Findings ................................................................................... 128
Results and Findings for Organizational Influences ....................................................... 129
Organizational Authority to Prioritize Health and Wellness .......................................... 130
Document analysis .............................................................................................. 130
Survey results ...................................................................................................... 132
Interview data...................................................................................................... 133
Appropriate Funding and Staffing .................................................................................. 134
Document analysis. ............................................................................................. 135
Survey data.......................................................................................................... 136
Interview data...................................................................................................... 137
Support of the Fire Chief and Wellness Champion ........................................................ 139
Document analysis .............................................................................................. 140
Survey data.......................................................................................................... 142
Interview data...................................................................................................... 143
Synthesis of Organizational Findings ............................................................................. 146
Chapter Five: Solutions, Implementation, and Evaluation .................................................. 150
Recommendations for Practice to Address KMO Influences ......................................... 150
Knowledge Recommendations ....................................................................................... 150
Developing a health and wellness educational framework and library .............. 151
Training BOSH stakeholders on health and wellness educational delivery ....... 152
Motivation Recommendations ........................................................................................ 153
Highlight the importance of preventability of heart attack, suicide, and cancer
death .................................................................................................................... 154
Organization Recommendations ..................................................................................... 156
Gaining authority to integrate health and wellness education into HCFR.......... 157
Bringing health and wellness research from the “ivory tower to the hose tower 159
Improve messaging and reporting to maximize chief and champion influence . 161
Integrated Implementation and Evaluation Plan ............................................................. 161
Implementation and Evaluation Framework ....................................................... 161
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 7

Organizational Purpose, Need, and Expectations ............................................... 162
Level 4: Results and Leading Indicators ............................................................. 163
Level 3: Behavior ............................................................................................................ 164
Critical behaviors ................................................................................................ 164
Required drivers .................................................................................................. 166
Organizational support ........................................................................................ 167
Level 2: Learning ............................................................................................................ 168
Learning goals ..................................................................................................... 168
Program ............................................................................................................... 168
Evaluation of the components of learning .......................................................... 171
Level 1: Reaction ............................................................................................................ 172
Evaluation Tools ............................................................................................................. 174
Immediately following the program implementation ......................................... 174
Delayed for a period after the program implementation ..................................... 174
Data Analysis and Reporting .............................................................................. 175
Summary ............................................................................................................. 176
Future Research .............................................................................................................. 177
Conclusion ...................................................................................................................... 178
References .................................................................................................................................. 181
APPENDIX A - Fire department call volume from 1980 to 2015 ........................................ 199
APPENDIX B - U.S. Firefighter Fatalities On-Duty Due to Sudden Cardiac Death 1977-
2016) ........................................................................................................................................... 200
APPENDIX C - Health and Wellness Educational Framework References ....................... 201
APPENDIX D - Interview Protocol ......................................................................................... 210
APPENDIX E - Survey Items .................................................................................................. 213
APPENDIX F - Survey Items, Mean, and Standard Deviation ............................................ 216
APPENDIX G - Health and Wellness BOSH Stakeholder Post-Training Evaluation ....... 218
APPENDIX H - Health and Wellness BOSH Stakeholder 3 Month Follow-Up Evaluation
..................................................................................................................................................... 221
APPENDIX I - Health and Wellness Data Analysis (Level 3) .............................................. 222
APPENDIX J - Recruitment Letter ........................................................................................ 223

HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 8

List of Tables
Table 1 Organizational Mission, Global Goal and Stakeholder Performance Goals ................. 17
Table 2 Knowledge Influences, Types, and Assessments for Knowledge Gap Analysis .............. 62
Table 3 Motivational Influences and Assessments for Motivation Gap Analysis ........................ 67
Table 4 Organizational Influences and Assessments for Organization Gap Analysis ................ 71
Table 5 Knowledge Needs ............................................................................................................ 96
Table 6 Mean and Standard Deviation for Survey Items on Physical and Behavioral Conceptual
Knowledge................................................................................................................................... 101
Table 7 Percentage of Interviewees That Identified Physical and Behavioral Health and
Wellness Issues and Lifestyle Factors ......................................................................................... 102
Table 8 Mean and Standard Deviation for Survey Items on Development and Delivery
Procedural Knowledge ............................................................................................................... 107
Table 9 Percentage of Interviewees That Identified the Main Parts of Effective Pedagogy and
Major Traits of an Effective Instructor ....................................................................................... 108
Table 10 Motivation Needs ........................................................................................................ 113
Table 11 Mean and Standard Deviation for Survey Items on Value of Health and Wellness
Education .................................................................................................................................... 116
Table 12 Mean and Standard Deviation for Survey Items on Attributing Positive Firefighter
Change to Education and to BOSH ............................................................................................ 123
Table 13 Organizational Needs ................................................................................................. 129
Table 14 Mean and Standard Deviation for Survey Items on BOSH Authority ........................ 132
Table 15 Mean and Standard Deviation for Survey Item on BOSH Resources ......................... 136
Table 16 Mean and Standard Deviation for Survey Item on Fire Chief and Member Commitment
..................................................................................................................................................... 142
Table 17 Summary of Knowledge Influences and Recommendations ....................................... 150
Table 18 Summary of Motivation Influences and Recommendations ........................................ 153
Table 19 Summary of Organization Influences and Recommendations .................................... 156
Table 20 Outcomes, Metrics, and Methods for External and Internal Outcomes ..................... 163
Table 21 Critical Behaviors, Metrics, Methods, and Timing for Evaluation ............................ 165
Table 22 Required Drivers to Support Critical Behaviors ........................................................ 166
Table 23 Components of Learning ............................................................................................. 170
Table 24 Evaluation of the Components of Learning for the Program ..................................... 171
Table 25 Components to Measure Reactions to the Program ................................................... 173
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 9

Table of Figures
Figure 1. Type of firefighter fatalities by year (IAFF, 2013). ....................................................... 24
Figure 2. Firefighter deaths at structure fires compared to structure fires (NFPA, 2009). ......... 25
Figure 3. A research-based health and wellness education framework. ...................................... 35
Figure 4. Conceptual framework of fire service health and wellness influences.......................... 74
Figure 5. A theory-based individual and organizational assessment framework. ........................ 77
Figure 6. Respondent view of if BOSH provided them enough physical health and wellness
education to develop a comprehensive curriculum on firefighter physical health and wellness. 99
Figure 7. Respondent view of if BOSH provided them enough behavioral health and wellness
education to develop a comprehensive curriculum on firefighter behavioral health and wellness.
..................................................................................................................................................... 100
Figure 8. Respondent view of if BOSH provided enough education on curriculum development to
develop a comprehensive curriculum. ........................................................................................ 106
Figure 9. Respondent view of if BOSH provided enough education on classroom instruction to
deliver a comprehensive curriculum. .......................................................................................... 106
Figure 10. Respondent view of if educating firefighters on physical and behavioral health and
wellness in the academy should be a priority for HCFR. ........................................................... 114
Figure 11. Respondent view of how important physical and behavioral health and wellness is in
the academy. ............................................................................................................................... 115
Figure 12. Respondent view of if educating firefighters on physical and behavioral health and
wellness throughout their careers should be a priority for HCFR. ............................................ 115
Figure 13. Respondent view of how important physical and behavioral health and wellness is in
throughout a firefighter’s career. ............................................................................................... 115
Figure 14. Respondent view on if education can change firefighters’ lifestyles and habits. ...... 122
Figure 15. Respondent view on if BOSH is capable of improving HCFR firefighters’ health and
wellness through education......................................................................................................... 123
Figure 16. Respondent view on if BOSH should have the authority to mandate physical and
behavioral health and wellness education. ................................................................................. 131
Figure 17. Respondent view on if BOSH receives enough resources to educate firefighters on
health and wellness throughout all stages of their career. ......................................................... 136
Figure 18. Respondent view on if the fire chief is fully committed to health and wellness
education. .................................................................................................................................... 141
Figure 19. Respondent view on if BOSH has at least one member that is fully committed to health
and wellness education. .............................................................................................................. 141
Figure 20. Health and Wellness Education Tracking (Level 3). ................................................. 222
Figure 21. Stakeholder Goal- 16 hours of Physical and Behavioral Health and Wellness
Education. ................................................................................................................................... 222
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 10

Abstract
Firefighters are dying more from health and wellness issues than from fires. Heart attack accounts
for roughly 50% of on-duty deaths. Off-duty deaths from cancer and suicide far outnumber heart
attack deaths. These three health and wellness issues have been a focus of fire service research as
potential job-related issues. However, like the U.S. general population, these three health and
wellness issues are highly preventable if the lifestyle risk factors involved are addressed early.
This research was conducted for Howard County Fire and Rescue (HCFR) in Howard County,
Maryland. HCFR has roughly 500 career firefighters and roughly 500 volunteer firefighters. It is
in central Maryland and serves over 320,000 citizens. HCFR firefighters did not have access to
initial or continuing health and wellness education. The overarching focus of this research was to
understand what knowledge, motivation, and organizational factors were needed to develop a
health and wellness educational curriculum, and what the solutions to those needs might be. The
participants of this study included 47 members of the Bureau of Occupational Safety and Health,
which included field and headquarters personnel. A mixed methods research study included
document analysis, surveys, and interviews. While HCFR had knowledge, motivation, and
organizational assets, development was needed in knowledge and organizational factors for a
health and wellness educational curriculum to be developed and delivered. National consideration
should be given to record and disseminate what initial and continuing health and wellness
education is available to firefighters either from the state training agency, or the fire department.

Keywords: Firefighter, Heart attack, Suicide, Cancer, Physical, Behavioral, Health, Wellness,
Education
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 11

Chapter One: Introduction
Firefighters are dying of preventable health and wellness issues more often than on-duty
deaths (Kunadharaju, Smith, & Dejoy, 2011; NFPA, 2017). Cardiac arrest caused over 50% of
on-duty firefighter deaths in 2015 (National Fire Protection Association [NFPA], 2016). Suicide
among firefighters is usually not an on-duty death. Furthermore, there is not a lot of research
available on firefighter suicide. However, one study by Stanley, Hom, Hagan, and Joiner (2015)
revealed that in a study of over 1000 active and retired firefighters that 15.5% had attempted
suicide compared to an estimated 1.9%-8.7% of the national population. In 2015, there were 94
documented cases of firefighter suicide (NFPA, 2016). Furthermore, the National Fallen
Firefighter Foundation (NFFF) estimates that a fire department is more likely to experience a
suicide by one of its members than a line of duty death (2014). Cancer is also a major cause of
death for firefighters and in 2015 just under 80 cancer deaths were reported (NFPA, 2016). Many
of the same lifestyle factors play a major role in firefighter heart attack, suicide, and cancer
which allows for preventative measures to be taken that will affect all three (Anand et al., 2008;
Eastlake, 2015; Henderson et al., 2016). However, Howard County Fire and Rescue does not
currently have an educational curriculum to address heart attack, suicide, and cancer.
Furthermore, a review of the published curriculum from the state fire training institution in
Maryland (Maryland Fire and Rescue Institute) revealed that there were no state-sponsored
health and wellness courses for firefighters (MFRI, 2016).
Organizational Context and Mission
The Bureau of Occupational Safety and Health (BOSH) is part of the administrative
structure of Howard County Fire and Rescue (HCFR), located in Howard County, Maryland. In
2014, BOSH was created within HCFR. The mission of BOSH is to develop and maintain an
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 12

innovative occupational safety and health program that fosters a safe work environment,
wellness, and healthy lifestyle.
Howard County Fire and Rescue is a combination career and volunteer municipal fire
department with 12 fire stations. As an all hazards emergency response department, HCFR
responded to roughly 40,000 calls in 2016 with 450 career personnel serving roughly 310,000
citizens. The municipality is both urban and rural and has major national and state transportation
routes going through it. In BOSH, there are four career staff members and two civilians as well
as a peer fitness team (PFT) and a peer support team (PST) that are comprised of career
firefighters who have volunteered to take on a collateral duty from the field. The director of
BOSH is an assistant chief and has a battalion chief, captain, and a firefighter as reports.
According the fourth needs assessment of the U.S. fire service in 2015, 68% of fire departments
that protect between 250,000-499,000 citizens had an IAFF/IAFC Wellness Fitness Initiative
(WFI) health and wellness program and 74% of fire departments in that category had a
behavioral health program (NFPA, 2016b).
Organizational Performance Need
In order to fulfill its mission and continue providing the best health and safety services
for its firefighters, BOSH needs to implement an initial and continuing health and wellness
education program. Failure to do so could result in preventable injuries, chronic illnesses, or
even deaths of its firefighters from physical or behavioral health and wellness issues.
Additionally, HCFR may be vulnerable to legal liability for failing to provide health and
wellness education to its members. HCFR has adopted the 16 Firefighter Life Safety Initiatives
from the NFFF. The initiatives are centered on cultural change and include physical and
behavioral health and wellness (NFFF, 2017). However, without initial and continuing health
and wellness education, it will be harder to change the culture of HCFR. These needs outline
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 13

some reasons as to why HCFR supported research on developing a program that offers initial and
continuing health and wellness education. At the beginning of this research, no such program
existed.
Related Literature
Heart attack, suicide, and cancer are the top three health and wellness issues for
firefighters (NFPA, 2017). Firefighters endure high stress, physically and mentally, and because
of occupational exposures may be at an elevated risk of heart attack, suicide, and cancer (IAFF,
2008; IAFF, 2013; NFFF, 2014; NFFF, 2016). However, preventable lifestyle factors are shown
to play a major role in firefighter heart attack (Eastlake, 2013; Soteriades, Smith, Tsismenakis,
Baur & Kales, 2011), suicide (Henderson, 2016), and cancer (Daniels et al., 2014). Lifestyle
factors such as activity, diet, and stress can increase heart attack risk (Soteriades et al., 2011;
Eastlake, 2013). Suicide risks are increased by depression, anxiety, substance abuse, and stress
(Henderson, 2016). One research study estimates that between 90% and 95% of cancers are now
deemed to be from lifestyle or environmental issues (Anand et al., 2008). Evidence suggests that
across the United States, most firefighters do not have access to health and wellness programs
(NFPA, 2016b).
A needs assessment for the U.S. fire service was conducted in 2001 which included data
on whether fire departments had programs dedicated to maintaining firefighter fitness and health
(NFPA, 2002). The assessment concluded that in 2001 only about 20% of fire departments had a
health and wellness program. The report indicated that for departments that protected
populations of 50,000 people or more, the number of departments with health and wellness
program was about 50%. In 2006, the NFFF held a health and wellness summit to seek advice on
best practices and strategies regarding firefighter life safety. The number one recommendation
made during this summit was that training and education must increase the knowledge and
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 14

understanding of NFPA’s medical and fitness standards and advocate their use (NFFF, 2006). In
2015, a fourth needs assessment was conducted for the U.S. fire service (there were assessments
done in 2001, 2005, and 2010). Just over a quarter (27%) of departments had a health and
wellness program, but this was down from 30% in 2010. Similar to the report in 2002, most of
the departments that did not have health and wellness programs protected less dense populations.
Data was not collected on whether an educational component existed for initial training (i.e. fire
academy) and for continuing education, and if so, what content was included and how many
hours were dedicated.
Importance of the Organizational Innovation
Developing a health and wellness education program for firefighters is important to
implement because physical and behavioral health and wellness are critical to the day-to-day
operations of responding to the emergencies of citizens. By educating 100% of its firefighters in
physical and behavioral health and wellness each year, HCFR will be investing in the health of
its human capital. Based on data collected from the NFPA (2016c) physical and behavioral
health and wellness issues account for far more deaths of firefighters than fires or other job-
related activities. Despite the efforts that exist, heart attacks have caused roughly half of on-duty
firefighter deaths over the last decade (NFFF, 2016; NFPA, 2016). Heart disease, suicide, and
cancer are also becoming more prevalent in general. The Centers for Disease Control and
Prevention (CDC) reported that from 2011-2014, rates for heart disease, which is already the top
killer in the United States, rose 3% (CDC-Number 254, 2016), and between 1999-2014 suicide
rates rose 24% (CDC-Number 241, 2016). The CDC notes that cancer is the second leading
cause of death in the United States and is very close to surpassing heart attack as number one.
The fire service cannot expect to see a reduction in heart attack, suicide, or cancer until initial
and continuing health and wellness education is taken seriously.
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 15

Legal liability is also an issue. If the fire service is going to claim that firefighters have
occupational risk factors of heart attack, suicide, or cancer (IAFF, 2008), then fire departments
could be at risk of negligence if they cannot properly demonstrate in court that firefighters were
educated on how to reduce those risks. Indeed, NFPA publishes industry standards that call for
fire departments to educate on health and wellness. The International Association of Firefighters
(IAFF) and the International Association of Fire Chiefs (IAFC) developed the Peer Fitness
Trainer (PFT) model and the Peer Support Team (PST) model (IAFF, 2016), and also call for
health and wellness education. However, it is not clear whether the departments that have PFT
and PST programs are using them for education in the academy and for continuing education, or
if they are resources that must be sought out by the firefighter and therefore provide no guarantee
of any minimum education before an issue arises. The consequences of not introducing a
comprehensive physical and behavioral health and wellness educational program include
increased risk of injury, illness, death, legal liability, and potential public relations and
reputational issues.
Organizational Performance Goal
The goal of BOSH was that by 2020, 100% of the department would receive physical and
behavioral health and wellness education every year of their career. To do this, BOSH will
design a minimum of 16 hours of deliverable, testable, and creditable curriculum that is
applicable to 100% of the members of the department. New recruits would receive at least 16
hours of health and wellness education in the academy. Veteran firefighters would receive at
least two hours of health and wellness education each year. This goal was presented by the
researcher who is a stakeholder of BOSH and was approved by the director. The standard of time
for the academy education was determined by college course work requirements set by the local
community college for a one-credit health introduction course. The hours for veteran firefighters
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 16

was determined by time constraints in scheduling and overtime budget. The hours will be tracked
through fire academy records and online continuing education training and assessments.
Description of Stakeholder Groups
The stakeholder groups for this study include three within HCFR and one group outside
of HCFR. The groups inside of HCFR include BOSH, Education and Training, and the Office of
the Fire Chief (OFC). The outside stakeholder is the Medical Assessment Contractor (MAC).
Howard County Fire and Rescue’s BOSH is the group responsible for developing policy,
standards, training, and education related to physical and behavioral health and wellness, as well
as occupational safety. The members for BOSH would be responsible for developing and
delivering education and training for health and wellness. Education and Training is HCFR’s
bureau responsible for initial training of firefighter-EMTs as well as coordinating and providing
facilities for the continuing education of veteran firefighters. The Office of the Fire Chief is
responsible for creating the vision for the department, as well as delegating authority for
implementing the vision. The Office of the Fire Chief has the final say on approving major
organizational changes especially regarding education, training, or media related information.
The Medical Assessment Contractor (MAC) is the office that conducts annual firefighter
physical assessments that include cardiac screening, blood tests, chest x-rays, and urine analysis,
as well as screening for hearing, vision, and respiratory function. The Medical Assessment
Contractor is tasked with reporting to HCFR, and to the screened firefighters, about current
health status and risk factors of those that receive an assessment (100% of HCFR professional
firefighters). Howard County Fire and Rescue is currently working with the volunteer
corporations to get as many volunteers assessed each year as possible.

HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 17

Stakeholder Groups’ Performance Goals
Table 1

Organizational Mission, Global Goal and Stakeholder Performance Goals
Organizational Mission
Develop and maintain an innovative occupational safety and health program that fosters a safe
work environment, wellness, and healthy lifestyle.
Organizational Performance Goal
By 2020, 100% of the department will receive physical and behavioral health and wellness
education every year of their career.
BOSH E&T
Medical Assessment
Contractor
Fire Chiefs
Office
By 2019, BOSH will
develop a minimum
of 16 hours of
deliverable, testable,
and creditable
curriculum on
physical and
behavioral health and
wellness that is
applicable to 100% of
the members of the
department.
By 2019, E&T will
have partnered
with BOSH to
evaluate and
support the
implementation of
a physical and
behavioral health
and wellness
curriculum to be
deliverable to all
new recruits.
By 2019, the Medical
Assessment Contractor will
have created a summary
report for each calendar
year deliverable to HCFR
with statistics on key
factors of HCFR’s
workforce, such as, but not
limited to, obesity rates,
high cholesterol rates,
cardiac risk factors, and
diabetes rates.
By 2019, the
Fire Chief will
have reviewed
and approved
the BOSH
initial and
continuing
education
program and its
funding.

Stakeholder Group for the Study
While the joint efforts of all stakeholder groups contribute to the achievement of health
and wellness goals in HCFR, it was important to understand the needs of BOSH stakeholders
since they would be developing and delivering health and wellness curricula. Therefore, the
stakeholders of focus for this study included only the 47 BOSH members. There were 47
personnel within BOSH.
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 18

The stakeholder groups’ goal, supported by the Director of BOSH, was that by 2019,
BOSH would have developed 16 hours of physical and behavioral health and wellness education.
Curriculum development for initial and continuing health and wellness education would include
activities such as relevant health and wellness research, curriculum design, written and electronic
file creation, assessment design and creation, and student transcript filing. Informal interviews
revealed that no BOSH initial or continuing health and wellness education program existed.
The stakeholder goal was determined by the organizational goal of having a program
ready to be delivered by 2020. The goal is in line with the vision of the department which is to be
a national model for fire service organizations in safety, health, and wellness. BOSH, which is
charged with keeping the firefighters of HCFR safe, healthy, and well, used the vision of being a
national model and applied it to its specific bureau responsibilities.
The members of BOSH were involved in constructing the goals of the health and
wellness educational program. The measurable goal of 100% of new recruits receiving initial
education and 100% of firefighters receiving continuing education was determined by assessing
needs and desires. HCFR needs to be protected from a liability standpoint by giving the
appropriate education necessary to its members on health issues that affect firefighters. However,
more importantly, HCFR wants to be proactive and prevent illness and injury before they occur,
and education is a major component of prevention.
Purpose of the Project and Questions
The purpose of this project was to conduct a needs’ analysis in the areas of knowledge,
motivation, and organizational resources necessary to reach the stakeholder goal of designing 16
hours of physical and behavioral health and wellness education. The stakeholder goal ultimately
supported the organizational goal of 100% of the department receiving initial and continuing
health and wellness education each year. While a complete needs’ analysis would have focused
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 19

on all stakeholders, for practical purposes, the stakeholders of focus were BOSH members as
they would be responsible for curricula design, development, evaluation, and implementation.
The analysis began by generating a list of possible needs and then examined these systematically
to focus on actual or validated needs.
As such, the questions that guided this study were the following:
1. What are the BOSH staff members’ knowledge, motivation, and organizational needs
related to designing and delivering a comprehensive curriculum on physical and
behavioral health and wellness that is applicable to 100% of department members?
2. What is the interaction between organizational culture and context and BOSH
members’ knowledge and motivation?
3. What are the recommended knowledge, motivation, and organizational solutions to
those needs?
Methodological Framework
Clark and Estes’ (2008) gap analysis, a systematic, analytical method that helps to clarify
organizational goals and identify the gap between the actual performance level and the preferred
performance level within an organization, was adapted for needs’ analysis as the research
framework. Assumed knowledge, motivation, and organizational needs were generated based on
personal knowledge and related literature. These needs were validated by using literature review,
surveys, interviews, and document analysis. Research-based solutions were recommended and
evaluated in a comprehensive manner.
This research study used a mixed-methods approach with an emphasis on qualitative
research. Descriptive surveys are often used in qualitative research (Creswell, 2014). A
descriptive survey using a Likert-type assessment was delivered to all 47 BOSH members. This
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 20

survey identified themes related to BOSH members’ perceptions of how prepared they were to
design and deliver health and wellness education. Secondly, it identified stakeholder
motivational factors toward health and wellness education. Lastly, it identified organizational
factors that affected health and wellness education. The survey served as a validating tool for
themes that arose during the interview process, and documents that were reviewed during the
document analysis process.
Along with surveys, qualitative research often uses other data collection methods to
explore the process, understanding, and meaning of what is being studied (Maxwell, 2013).
Merriam and Tisdell (2016) stated that by using these different types of data collection methods,
the research can triangulate the data, which can be used to limit potential bias in the conclusion.
An in-person interview and document analysis were conducted which expanded on the survey
data about knowledge, motivation, and organizational sentiment. The interviews sought to
understand the knowledge, motivation, and organizational factors that may have existed, and
those that may have been needed by BOSH members to develop and deliver initial and
continuing health and wellness education. Qualitative research focuses on exploring meaning and
experience (McEwan & McEwan, 2003), and this research was interested in why HCFR did not
have initial or continuing health and wellness education and what factors were needed to do so.
Definitions
BOSH - Bureau of Occupational Safety and Health (in HCFR)
CDC - Centers for Disease Control and Prevention
E&T - Education and Training (in HCFR)
HCFR - Howard County Fire and Rescue
IAFC - International Association of Fire Chiefs
IAFF - International Association of Firefighters
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 21

LODD - Line of Duty Death
MFRI - Maryland Fire and Rescue Institute
NIOSH - National Institute for Occupational Safety and Health
NFFF - National Fallen Firefighters Foundation
NFPA - National Fire Protection Association
OSHA - Occupational Safety and health Administration
PFT - Peer Fitness Trainer
PST - Peer Support Team
WFI - Wellness Fitness Initiative
Organization of the Study
Five chapters were used to organize this study. This chapter provided the reader with the
problem of practice being researched, the organization’s mission, goals, and stakeholders, as well
as the initial concepts of gap analysis adapted to needs analysis. Chapter Two provides a review
of current literature surrounding the scope of the study. National statistics on firefighter mortality
and the associated health and wellness issues are discussed, as well as health and wellness
initiatives at the national, state, and local level. Chapter Three details the assumed needs for this
study as well as methodology regarding choice of participants, data collection and analysis. In
Chapter Four, the data and results are assessed and analyzed. Chapter Five provides
recommendations, based on data and literature, for addressing BOSH’s needs as well as
recommendations for further research.

HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 22

Chapter Two: Review of the Literature
Firefighters are dying of preventable health and wellness issues more often than on-duty
deaths (Kunadharaju, Smith, & Dejoy, 2011; NFPA, 2017). In fact, heart attacks are the leading
cause of line of duty deaths and make up almost 50% of all line of duty deaths (NFPA, 2017).
Needs assessments conducted by NFPA for the U.S. fire service show that many fire departments
in densely populated areas report having health and wellness programs (NFPA, 2016b).
However, the needs assessment did not collect data on what education was available to
firefighters on how to prevent the most common issues of heart attack, suicide, and cancer
(NFPA, 2016b). In Maryland, no training on these issues was available through the Maryland
Fire and Rescue Institute (MFRI) according to their course curriculum (MFRI, 2018). The
purpose of this research was to understand why HCFR does not have initial and continuing
health and wellness education, and what may be needed to support educational efforts going
forward.
This chapter will include a review of relevant research, and a model of the conceptual
framework that will be used for the data collection. The review of the literature will explore
firefighter death statistics, national fire service trends, research specific to firefighter health and
wellness, and general research on heart attack, suicide, and cancer. It will also examine fire
service health and wellness initiatives and education from the national, state, and local level.
Furthermore, the relevant knowledge, motivation, and organizational theoretical literature will be
discussed which will lead into the key knowledge, motivation, and organizational (KMO)
influences related to BOSH. Following the general research literature, the review turns to the
Clark and Estes (2008) Gap Analysis Conceptual Framework and, specifically, knowledge,
motivation and organizational influences on BOSH’s ability to develop and implement an initial
and continuing health and wellness curriculum.
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 23

Health and Wellness in the Fire Service at the National Level
The following section is an overview of fire service related literature from a national
perspective. This section begins by reviewing the national fatality trends and the top health and
wellness issues of firefighters as documented by NFPA (2017), which are heart attack, suicide,
and cancer. Some of the existing research on lifestyle factors of these issues is included and is
presented in a graphical format using a concept map as seen in Figure 3. This section then
presents a brief summary of what recommendations and initiatives exist at the national level of
both government and non-governmental fire service organizations.
Firefighter Fatality Trends
The National Fire Protection Association (NFPA) keeps statistics on a wide range of
issues that affect the fire service. The NFPA produces a yearly firefighter fatality report that
documents the causes of death for firefighters, including data on heart attack, suicide, and cancer.
While exact numbers on suicide and cancer deaths in the fire service are not yet possible, the
data from NFPA represents the most accurate numbers available currently. The following section
briefly reviews the trend changes in call volume for the fire service, as well as trends on heart
attack, suicide, and cancer in the fire service.
A changing fire service. The nature of day-to-day emergency calls of fire departments in
the United States has changed dramatically over the last four decades. According to NFPA
statistics, fire related calls have decreased from 2.9 million nationwide in 1980, to 1.3 million
nationwide in 2015 and now make up only 4% of all calls (Appendix A) (NFPA, 2017). Fire
departments are now responding, on average, to almost three times as many calls as they did in
1980 (7.9 million to 22.8 million), however 96% of total calls are not for fires (NFPA, 2017).
The bulk of call volume for fire departments has shifted to emergency medical service (EMS)
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 24

responses (Braedley, 2015; NFPA, 2017). Oddly, even though responses to fires have gone
down, the percentage of heart attack deaths for firefighters while on duty have not.
Heart attack. Firefighter’s number one cause of death in the line of duty is heart attacks,
and it has remained that way since at least 1977 (NFPA, 2017). The fire service has argued that
heart attack on duty is linked to occupational risks (IAFF, 2008; IAFF, 2013; NFFF, 2016).
Though the long-term trend of total firefighter on-duty-deaths per year has dropped almost in
half, heart attacks remain the number one cause of on-duty death (Appendix B) (NFPA, 2017).
Figure 1 graphically presents all firefighter fatalities against sudden cardiac death (heart attack)
fatalities of firefighters. Figure 2 presents that there is a correlation between structure fires and
firefighter deaths at structure fires, and that structure fires are declining.

Figure 1. Type of firefighter fatalities by year (IAFF, 2013).
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 25

Figure 2. Firefighter deaths at structure fires compared to structure fires (NFPA, 2009).
The amount of fire calls per year has dropped slightly more than half from 1980 to 2015
(NFPA, 2017) (Appendix A). There appears to be a relationship in the reduction in firefighter
fatalities due to the reduction in fire responses. However, even though total on-duty deaths have
reduced by roughly half, heart attacks still make up 40-50% of total on-duty deaths. Therefore,
whatever is responsible for firefighter heart attacks on duty has not been addressed in any
meaningful way. In fact, when looking at recent decades, the trends appear to be worsening.
While overall fire-related fatalities may be decreasing, heart attack rates and stroke
among firefighters may be increasing (Kahn, Woods, & Rae, 2015). Kahn et al. (2015) found a
rise in heart attack related on-duty deaths from 43% to 46.5% between the decades of 1990 to
2000 and 2000 to 2010. In 2015 and 2016, deaths from heart attack made up 51% and 38%
respectively, however in 2016, deaths from vehicle crashes unexpectedly spiked to 25% from
12% in 2015 (Fahy, LeBlanc, & Molis, 2017). This gives the appearance that heart attack rates
fell, when in fact fire department related crashes unexpectedly rose. Dr. Fahy stated in a phone
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 26

interview (September 18, 2017), regarding her data on fatalities, that most of the years that report
heart attack percentages in the 30’s is a result of groups of firefighters dying at once due to
building collapses, vehicle crashes, or the like.
Research has been done to identify what factors are involved in the deaths of firefighters
where heart attack is the cause. Kales et al. (2003) found that on-duty firefighter deaths from
heart attack were correlated with emergency responses. Furthermore, they found that the more
strenuous the activity, the higher the risk of cardiac related death. The correlation of strenuous
activity and higher risk of cardiac death seems to suggest that heart attacks may be due to
firefighting, rescue, or EMS work. However, their study goes on to explain that the more
cardiovascular disease (CVD) risk factors, the higher the risk of dying during strenuous activity,
and conversely, heart attack related deaths are unlikely to occur in firefighters without CVD risk
factors. Indeed, Soteriades et al. (2011) concluded that heart attacks in firefighters are not
random; 90% of firefighters that die of heart attack have cardiovascular disease or other risk
factors.
There are many factors that increase risk of cardiovascular disease. Researchers have
identified smoking, hypertension, diabetes, abnormal cholesterol, prior diagnosis of
cardiovascular disease, and obesity as some of the known risk factors for firefighters (IAFF,
2013; Kales et al., 2003; Soteriades et al., 2005). Obesity and hypertension have been
specifically targeted as major risk factors (Soteriades et al., 2005). Because obesity is such a
major factor for firefighter heart attacks, it is worth looking into the literature to determine the
rates of firefighter obesity against the general population. According to the Centers for Disease
Control and Prevention data in 2014, the United States population was 36.5% obese (Ogden et
al., 2015) and 70.7% overweight (National Center for Health Statistics, 2017). Kay et al. (2001)
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 27

revealed that roughly 34-45% of firefighters were classified as obese and about 80% of
firefighters were overweight. A decade later, Poston et al. (2011) found that firefighter obesity
rates were still roughly the same. In comparison with other occupations, male firefighters made
up the third highest obesity group (Caban et al., 2005; Choi et al., 2011). Based on the general
population and firefighter specific data, it appears that the rates of obesity and overweight people
in the United States are very similar to those in the fire service. In contrast, the military’s obesity
rate is 12% (Reyes-Guzman et al., 2015; Smith et al., 2012).
Hypertension is another major issue and presents a growing problem in the fire service.
Approximately 20-23% of firefighters are hypertensive and 50% are pre-hypertensive (Kales et
al., 2009). To add to that, roughly three quarters of those with hypertension did not have
adequate control over the condition and showed no improvements even after four years of face to
face interviews with doctors (Kales et al., 2009). To compare, the U.S. population is roughly
30% hypertensive but only about 33% are pre-hypertensive (National Center for Health
Statistics, 2017). Because of the high number of pre-hypertensive firefighters, Kales et al. (2009)
suggested that hypertension is likely to rise in the fire service unless something is done.
Both obesity and hypertension are preventable risk factors (Crowley & Lodge, 2007;
IAFF, 2013; Kales et al., 2003; Soteriades et al., 2005). According to Crowley and Lodge (2007),
exercise is the main driver for reversing the causes of heart disease. Lodge stated that while we
cannot control our age, we can control our rate of decay, which is increased by sedentary
behavior and is a major factor in obesity, hypertension, and other chronic illnesses.
Over the last 40 years, fire service deaths have dropped almost in half compared to what
they were in the late 1970’s (NFPA, 2017). This drop seems to be in line with the decrease in fire
related calls from the early 1980’s until today (NFPA, 2017). However, what has not changed is
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 28

the rate of line-of-duty deaths attributed to heart attack which has remained at the 40-50% level
(NFPA, 2017) and could be growing (Kahn et al., 2015).
Firefighter health at-large seems to be tracking very closely to the U.S. general
population numbers regarding obesity and hypertension (Caban et al., 2005, Choi et al., 2011;
Kay et al., 2001; National Center for Health Statistics, 2017) despite a specific focus on
firefighter heart attack issues by the IAFF, NFPA, and NFFF. Throughout the literature on heart
attack in the fire service, lifestyle continues to be the major factor that researchers point to as the
leading cause of heart attack in firefighters (IAFF, 2013; Kahn et al., 2015; Kales et al., 2003;
Soteriades et al., 2005). Heart attack is still the number one cause of on-duty death in the fire
service (NFPA, 2017) as well as in the United States (National Center for Health Statistics,
2017), however two other causes of death have also risen dramatically in the general population
and are affecting firefighters as well: suicide and cancer.
Suicide. For firefighters, suicide is another major issue with 99 known suicides in 2016
(NFPA, 2017). Although firefighter suicides occur mostly off duty, an NFFF (2014) report
revealed that a fire department is three times more likely to experience a suicide of one of their
members than a line of duty death. The NFFF report highlights that because death records have
not included occupation, there is no way to tell if firefighter suicide rates are higher than the U.S.
general population. However, the fire service has voiced its concerns about suicide and
behavioral health issues being linked to occupational risk factors (IAFF, 2008; NFFF, 2014).
From 1999 to 2015, suicide rates increased 24% in the United States (CDC, 2016). Males
appear to be roughly three times more likely to commit suicide than females (CDC, 2016).
Furthermore, other than American Indian or Alaskan Natives, White males had the highest rate
of suicide as a demographic group (CDC, 2016). The U.S. fire service is currently comprised of
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 29

mostly White males (NFFF, 2014; NFPA, 2016), so the high suicide rate in the fire service could
be a reflection of the national statistics of White males, that is perhaps compounded by
occupational factors.
A closer look at suicides and occupational trends is warranted. However, the research is
limited. The CDC recently looked at different occupational groups and controlled for gender and
age while investigating suicide rates (McIntosh, 2016). McIntosh found that while the U.S.
general population has a rate of 16.1 suicides per 100,000 people, the occupational classification
that firefighters fall under (protective services) has a rate of 30.5 per 100,000. However,
McIntosh noted that protective services consist of police, fire, and security services, and includes
military members in this group if their job falls into any of these categories. In contrast, a
military study that was done before the war in Iraq and Afghanistan began, found that military
suicide is no different than the U.S. general population and may be lower (Eaton et al., 2006).
One of the few studies on firefighter suicide found that 1.9%- 8.7% of the U.S. general
population has attempted suicide, yet the number is 15.5% for firefighters (Stanley et al., 2015).
If the higher rate of suicide attempts in firefighters is true, it may be because of the higher level
of factors that contribute to mental health issues. Past research on psychological autopsies
suggest that roughly 90% of people who commit suicide have a mental disorder (Cavanagh,
Carson, Sharpe & Lawrie, 2003; Harris & Barraclough, 1997).
More studies have been conducted on mental health in firefighters than on suicide.
Factors such as depression, anxiety, stress (and PTSD), substance use and abuse, sleep
disturbance, and frequency of witnessing traumatic injury on emergency calls have been
identified in firefighters (Carey et al., 2011; Haddock et al., 2015; Henderson et al., 2016).
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 30

Specifically, firefighters have high levels of substance use or abuse, high levels of stress, and
high levels of sleep disturbance (Haddock et al., 2015; Henderson et al., 2016).
Interestingly, a study from Europe on adolescent suicide may help the U.S. fire service in
its understanding of suicidal risk factors. Carli et al. (2014) identified what is being termed as the
“invisible risk” group for adolescent suicide, as compared to high risk and low risk groups. The
study found that the high-risk group factors included substance or alcohol abuse, smoking, sleep
disturbance, sedentary behavior, high media use, and high truancy rates, while the low risk group
had none of these. However, the newly identified “invisible” risk group has three main risk
factors which include reduced sleep, sedentary life, and high media use (Carli et al., 2014).
Assuming one excludes all high-risk behaviors such as use or abuse of substances, alcohol abuse,
or smoking, the fire service still has two out of the three “invisible risk” group factors
documented by research as it is struggling with sedentary lifestyle issues and sleep disturbances.
Methods for how to improve and maintain mental health can be found in published
research. There is research conducted specifically with firefighters, and also with the general
public, that reveal ways to reduce stress, depression, anxiety and other symptoms that are
associated with behavioral disorders and suicide. Mindfulness and personal mastery practices
have been shown to reduce stress, depression, physical health symptoms, and alcohol problems
in firefighters (Smith et al., 2011). Other research has shown that emotional intelligence and
proactive coping can reduce PTSD, depression, and anxiety symptoms in firefighters (Wagner &
Martin, 2012). More generally, exercise has been shown to reduce stress, depression, anxiety,
ADD and ADHD, and even addiction, while also increasing cognitive performance (Ratey &
Hagerman, 2008; Sapolsky, 2004). Furthermore, positive attitudes and social bonding also
protect against mental health issues and help to reduce stress (Sapolsky, 2004).
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 31

Fire departments are dealing with more off-duty deaths from suicide than by on-duty
deaths (NFFF, 2014; NFPA, 2017). However, the United States has also seen a steep increase in
the rate at which people are committing suicide, and White men (the majority of U.S.
firefighters) make up the largest group affected (CDC, 2016). Although there are not many
studies currently about firefighter suicide, there are studies about firefighter behavioral health
and the factors involved.
If the psychological autopsy studies are true, and 90% of those who commit suicide have
a mental disorder (Cavanagh, Carson, Sharpe & Lawrie, 2003; Harris & Barraclough, 1997),
focusing on the prevention and reduction of mental disorders and mental illness should be a
strong consideration for firefighters. The research on firefighter and general population studies
seem to suggest that this can be done by managing healthy lifestyle practices (Carey et al., 2011;
Haddock et al., 2015; Henderson et al., 2016; Ratey & Hagerman, 2008; Sapolsky, 2004).
Suicide is a major issue for firefighters with 99 deaths in 2016 however, there is one other major
cause of death that is affecting firefighters: cancer (NFPA, 2017). In 2016, cancer was the
recorded cause of death for 80 firefighters (NFPA, 2017).
Cancer. Cancer is close to surpassing heart attack as the leading cause of death in the
United States (CDC, 2016) and is a major health and wellness issue for firefighters. Currently,
cancer is the leading cause of death in 22 states (CDC, 2016). From 2000 to 2014, cancer deaths
increased by a modest rate of about 1.7%. However, in 2014 the total number of U.S. deaths due
to cancer was 591,699, very close to the total deaths due to heart disease at 614,348 (CDC, 2016-
Figure 1).
Cancer has been a focus of the fire service because of concerns of occupational exposure
to carcinogens (Daniels et al., 2014; Daniels et al., 2015; NFFF, 2017). Indeed, the IAFF/IAFC
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 32

WFI has pushed for preventive measures (IAFF, 2008). Although there is an ongoing debate
about how much risk of cancer is associated with firefighting, the literature suggests that there is
some additional increase of cancer in firefighters (Tsai et al., 2015).
The National Institute for Occupational Safety and Health (NIOSH) recently concluded
that compared to the U.S. general population, firefighters face a 9% increase in cancer diagnoses,
and a 14% increase in cancer-related death (Daniels et al., 2014; Daniels et al., 2015). The
NIOSH studies were able to show links to fire exposure and lung cancer during a time when
respiratory protection may not have been as efficient as it is today (Daniels et al., 2014; Daniels
et al., 2015). In addition, the two studies looked at cancers of the brain, abdomen, and blood,
with the majority of cancers being of the abdomen (Daniels et al., 2014; Daniels et al., 2015).
While firefighters and industry leaders are raising awareness of firefighter cancers due to
carcinogen exposures, there is one study that suggests firefighter cancer could be coming from
elsewhere. Milham (2009) argued that respiratory system cancers are not as increased in
firefighters the way they are in other industry workers that are exposed to known inhaled
carcinogens. Instead, he argued that the list of cancers with increased risk for firefighters
strongly overlaps with cancers from workers exposed to electromagnetic fields and radio
frequency radiation (Milham, 2009). The study included a meta-analysis of firefighter cancer
studies. He showed that of the cancers that are probably associated with firefighting, 50%- 60%
of them are abdominal region cancers, and of the cancers that are possibly associated with
firefighting 33% are abdominal region cancers (Milham, 2009).
The high amounts of abdominal region cancers are concerning because of research done
on cancer in the general population which shows a strong link between obesity and cancer (Calle
& Thune, 2004; Calle & Kaaks, 2004; Carroll, 1998; Williams, 2013; Wolin et al., 2010). The
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 33

link between obesity and cancer is troubling because firefighters have an obesity rate that may be
higher than the general population (NFFF, 2016). Cancer of the abdominal region turns out to be
highly correlated with excess weight, with roughly 20% of all cancer cases are attributed to
weight, weight gain, and obesity (Williams, 2013; Wolin et al., 2010).
The cancers that are highlighted by the NIOSH firefighter cancer studies (Daniels et al.,
2014; Daniels et al., 2015) have a high rate of overlap with those that are correlated to cancers in
obese populations (Williams; 2013; Wolin et al., 2010). Williams (2013) explains that the issue
is not even obesity per-se, but excess fat cells in general and that there is a positive relationship
between the amount of fat one has and the rate of cancer growth. In other words, there is not an
invisible threshold that separates cancer risk from those who are overweight and those who are
obese. Carroll (1998) explains that weight gain affects the metabolic functions of the body which
is a factor in cancer pathology and thus overeating may be the largest avoidable cause of cancer
in non-smokers. The top recommendation from Carroll (1998), nearly two decades ago, was to
improve education and messaging for physical activity and nutrition.
Within the past five years, major groundbreaking announcements have been made for
cancer research. In 2016, the Nobel Prize in Physiology or Medicine was awarded to Yoshinori
Ohsumi for his 25 years of contribution to science in understanding a process known as
autophagy (Larsson & Masucci, 2016). Autophagy means self-eating and is a natural process of
the body. Fasting and calorie restriction increases autophagy which destroys and recycles old and
damaged cells including cancer cells (Kondo & Kondo, 2005; Mathew, Karantza-Wadsworth, &
White, 2007; Mathew et al., 2009). Furthermore, shortly before Ohsumi was awarded the Nobel
Prize, Seyfried published two papers about the metabolic and mitochondrial link to cancer
(Seyfried et al., 2014; Seyfried, 2015). Seyfried (2014) made the connection that mitochondrial
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 34

health rises due to exercise or fasting because both activities activate the stress response and
stimulate a natural growth function. In short, sedentary life and over eating are shown to be
contributors to cancer.
Cancer is a major health and wellness issue for firefighters (NFPA, 2017). Occupational
risks do play a role and NIOSH reported that firefighters have a 9% higher risk of cancer and a
14% higher risk of cancer-related death than the general public for the cancers that were studied
(Daniels et al., 2014; Daniels et al., 2015). However, these findings must be reconciled with
other research that suggests that firefighters may actually have a less healthy lifestyle on average
leading to higher overweight and obesity rates compared to the U.S. general population (Choi et
al., 2011; Kales et al., 2009; Kay et al., 2001). Lifestyle is important to consider since cancer has
been directly tied to excess weight and obesity (Calle & Thune, 2004; Calle & Kaaks, 2004;
Carroll, 1998; Williams, 2013; Wolin et al., 2010). Indeed, one study suggests that up to 95% of
cancers are preventable through lifestyle or environmental changes (Anand et al., 2008).
Some of the most common risk factors associated with heart attack, suicide, and cancer
all appear to share lifestyle factors. Although the literature presented throughout this dissertation
is not exhaustive, there is enough to develop a framework of research that can be used for heart
attack, suicide, and cancer education in the fire service. The following section explores an
example of a research-based framework for heart attack, suicide, and cancer.
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 35

A research-based framework for heart attack, suicide, and cancer education.

Figure 3. A research-based health and wellness education framework.
The chart in Figure 3 presents a graphical representation of some of the existing research
on heart attack, suicide, cancer, and some of the main associated risk factors. Each link is
associated with at least one research study and can be found in Appendix C. By using a graphical
representation of research, it becomes clear that heart attack, suicide, and cancer share links to
each other regarding lifestyle factors of physical activity, nutrition, and mental activity. There are
occupational factors involved in firefighting such as physical stress (IAFF, 2013), mental stress
(NFFF, 2014), and toxin exposure (Daniels et al., 2014; Daniels et al., 2015), that may increase
the risk of heart attack, suicide, and cancer. However, lifestyle factors also play a role in
preventing these fatal health issues.
Firefighters, similar to the general population, are dealing with preventable health and
wellness issues resulting in heart attack, suicide, and cancer death. First, firefighter heart attacks
are preventable through lifestyle adjustments (Eastlake et al., 2013; IAFF, 2013; Kahn et al.,
2005; Kales et al., 2003; Kunadharaju et al., 2011; Soteriades et al., 2005). However, Soteriades
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 36

et al. (2005) found that 90% of all firefighters who died of heart attack had coronary heart
disease and that aggressive preventive measures should be taken. Secondly, according to
psychological autopsy studies, 90% of those that commit suicide have at least one diagnosable
psychiatric disorder (Cavanagh, Carson, Sharpe & Lawrie, 2003; Harris & Barraclough, 1997).
However, research suggests that mental health can be improved with lifestyle adjustments (Carey
et al., 2011; Haddock et al., 2015; Henderson et al., 2016; Ratey & Hagerman, 2008; Sapolsky,
2004). Lastly, up to 95% of cancers may be preventable (Anand et al., 2008). Even if these
numbers represent the highest possible number of a range, the literature provides a common
theme of preventability across all three health and wellness issues. Therefore, even though the
fire service has known occupational risks involved, the top three health and wellness issues for
firefighters must be considered through a preventable lifestyle framework as well.
Together, the emergency response statistics and firefighter fatality trends provide
important context for the health and wellness issues that the fire service is facing. Emergency
responses for fires have dropped significantly across the United States and responses for
emergency medical services have risen. However, firefighters are still dying on duty most of
heart attacks, and there is an increasing concern of cancer and suicide for the fire service.
Because of these health issues, the fire service associations at the national level, and even the
federal government, have responded. The following section is a review of those responses.
Industry and Government Recommendations and Initiatives
At the national level, the fire service industry has a few very prominent organizations that
make up the majority of the industry recommendations, standards, and requirements. Three
organizations that will be explored include the International Association of Firefighters (IAFF)
which is the firefighter’s union for the United States and Canada (IAFF, 2017); the National Fire
Protection Association (NFPA, 2017); and the National Fallen Firefighters Foundation (NFFF,
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 37

2017). The federal government creates regulations for occupational health, researches
occupational deaths, and has written law to support families affected by public safety fatalities.
The Occupational Safety and Health Administration (OSHA) oversees all occupational
health regulation for the United States (OSHA, 2017). The National Institute of Occupational
Safety and Health (NIOSH) (CDC, 2017) is an organization nested within the Centers for
Disease Control and Prevention (CDC) dedicated to research related to occupational safety and
health, and more specifically to line-of-duty death investigations. Furthermore, the U.S. Federal
Government has also passed and updated the Public Safety Officers Benefit Act (PSOB)
(Subchapter XI, Title 34 U.S.C.) which is designed to support the families of fallen public safety
officers. The following section provides an overview of the recommendations and initiatives of
both the non-government and government organizations regarding health and wellness of
firefighters.
The International Association of Fire Fighters (IAFF). The International Association
of Fire Fighters (IAFF) and the International Association of Fire Chiefs (IAFC) partnered in the
mid 1990’s to deliver a continual message about health and wellness (IAFF, 2008). The
partnership was named the IAFF/IAFC Joint Labor Management Wellness-Fitness Initiative
(WFI) and began with a focus on medical evaluation, fitness, and injury and medical
rehabilitation. The IAFF/IAFC WFI has released three editions of their initiative (1997, 1999,
and 2008). The latest edition includes a section on behavioral health for firefighters (IAFF,
2008). The WFI is designed to provide information about why a long-term commitment to
wellness should be considered and how to implement such a commitment (IAFF, 2008).
There are two main features of the IAFF/IAFC WFI. The first is the Peer Fitness Trainer
(PFT) program, and the second is the Peer Support Team program (PST) (IAFF, 2008). The PFT
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 38

program is recommended to be an educational and rehabilitative program, not a punitive one.
More specifically, the WFI suggests that PFTs should be educating firefighter recruits in the
academy, as well as during their careers, about initiating and maintaining fitness and wellness.
The WFI also suggests that fire departments have a specialist with advanced education and a
thorough knowledge of the job that can oversee the group of fitness trainers. The specialist
should remain current on the literature and have the ability to conduct ongoing research about
health and wellness. The specialist is a distinction from the PFT, and the WFI specifically
encourages all health professionals including the PFTs to supplement their initial certifications
with further advanced training (IAFF, 2008).
The second feature is the Peer Support Team program. The WFI behavioral support
program started with the Critical Incident Stress Management model (IAFF, 2008). However,
after research that the CISM model may be ineffective and even harmful in certain situations
(Van Emmerik et al., 2002, Rose et al., 2002), the IAFF switched to the current PST model
(IAFF, 2017). The PST model is intended to provide training to firefighters on how to provide
initial behavioral health support, education, and guidance about available resources to peers. One
of the resources is a new behavioral health center built and maintained by the IAFF that is
dedicated to helping firefighters recover from behavioral health issues and return to the job
(IAFF, 2017). This center is only for IAFF members and offers recovery from substance abuse,
PTSD, depression, and anxiety. However, there are other recovery centers in the United States
dedicated to public safety.
The IAFF has been, and is continuously active in, responding to health and wellness
threats to the fire service. Through its partnership with the IAFC to create the Wellness Fitness
Initiative, it has provided the fire service with one strong message and two strong models that
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 39

fire departments can use: The Peer Fitness Trainer model, and the Peer Support Team model.
The message is that education and training for firefighters is critical for physical and behavioral
health and wellness (IAFF, 2008; IAFF, 2017). At this time however, the IAFF does not offer a
curriculum for adoption and delivery in a fire academy that is specifically designed to educate
firefighters on health and wellness with regards to preventing heart attack, suicide, or cancer.
Other prominent national organizations also continue to contribute to the fire service
recommendations and available resources. The National Fire Protection Association and the
National Fallen Firefighters Foundation are non-governmental organizations that are not directly
tied to the national fire service the way the IAFF is. The following section includes a review of
those two organizations’ recommendations and initiatives.
Non-governmental organizations. The National Fire Protection Association (NFPA) is
a non-profit organization that recommends industry standards for the fire service. While the
standards offered by NFPA are not required to be adopted, the intent is to anticipate and amend
standards as necessary for fire departments to adopt when they are ready to do so. NFPA offers
two major industry standards that focus of health and wellness.
The first standard, NFPA 1500 is subtitled the Standard on Fire Department Occupational
Safety and Health Program (NFPA, 2012). This standard recommends that a fire department
should establish a health and fitness program in order to develop and maintain fitness of its
members (NFPA, 2012). It also recommends providing a behavioral health program and a
wellness program that provides prevention strategies that, whenever possible, is research based
and peer reviewed (NFPA, 2012).
The second standard, NFPA 1583 is subtitled the Standard on Health Related Fitness
Programs for Fire Department Members (NFPA, 2015). This standard specifically recommends
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 40

that fire departments should provide health promotion education as an integral part of the health
and wellness program (NFPA, 2015). The standard goes further and states that the education
should include health risk reduction, cardiovascular risk reduction, general health maintenance,
and prevention of occupational illness, injuries, accidents and fatalities (NFPA, 2015). This last
part is important because it echoes what OSHA obligates employers to do as a general rule as
will be reviewed in the next section (OSHA, 2015).
The NFPA exists to build scientifically backed, consensus standards that fire departments
can adopt when they are ready (NFPA, 2017). The standards that NFPA releases are tools that
fire departments can use to shape their organizations to perform better. However, NFPA is more
focused on research and information sharing then actively attempting to change the fire service
culture at the ground level. The National Fallen Firefighters Foundation (NFFF) is currently
filling that function.
The NFFF is a non-profit organization that was initially created by congress to honor and
remember the firefighters that have died in the line of duty (NFFF, 2017). The NFFF has
published a document known as the 16 Life Safety Initiatives that it advocates for nationally
through a network of regional and state advocates. The first of the 16 Life Safety Initiatives is
cultural change. The NFFF is actively involved in trying to change the culture through classes
that it delivers such as 1) Leadership so Everyone Goes Home, 2) Courage to be Safe, 3)
Leadership, Accountability, Culture, and Knowledge, and 4) Stress First Aid (NFFF, 2017).
The NFFF has also been integral in bringing conversation and information about cancer
to the fire service. It used its network to bring the fire service industry together to take action on
cancer in the fire service, resulting in an entity called Fire Service Occupational Cancer Alliance
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 41

(FSOCA) (NFFF, 2017), which is focused on awareness, prevention, and legislation. In 2017, the
Firefighter Cancer Registry Act passed through the U.S. House of Representatives.
While the IAFF has provided tools to help fire departments respond to physical and
behavioral health issues such as the PFT program and the PST program, the NFPA and NFFF are
providing other tools. The NFPA provides the architecture for what a health and wellness
program should address if it is adopted (NFPA, 2017), and the NFFF is providing ground level
awareness and education about changing fire service culture through its national advocate
network (NFFF, 2017). At this time however, neither the NFPA nor the NFFF offers a
curriculum for adoption and delivery in a fire academy that is specifically designed to educate
firefighters on health and wellness with regards to preventing heart attack, suicide, or cancer.
The IAFF, NFPA, and NFFF are three of the main organizations in the fire service that
are encouraging fire departments to take health and wellness seriously. None of these
organizations can enforce health and wellness education. However, the federal government can
enforce regulations and pass law. The next section considers the regulations, recommendations,
and legislation of the federal government.
The U.S. Federal Government. The Occupational Safety and Health Administration
(OSHA) is responsible for assuring safe and healthful working conditions for workers in the
United States. The OSHA Act of 1970 states that employers are responsible for providing a safe
and healthful workplace, and that employees should not have to suffer illness, injury, or death for
a paycheck (OSHA, 2015). The act suggests that employers keep a record of all safety and health
training in order to avoid lacking proof of training in the event of an investigation (OSHA,
2015). While OSHA does not enforce fire departments to educate firefighters specifically on
health and wellness issues, it emphasizes broadly that workplace training and education exists to
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 42

prevent occupational injury, illness, and death before they occur (OSHA, 2015). This message of
preventative training and education is echoed by NIOSH.
The National Institute for Occupational Safety and Health (NIOSH) is a division of the
Centers for Disease Control and Prevention (CDC) that conducts research on workplace safety
and health issues. Every line-of-duty death is investigated by NIOSH and recommendations are
then given on how to prevent such a death in the future. Kunadharaju, Smith, and Dejoy (2011)
conducted an analysis of NIOSH firefighter fatality investigations from 2004 to 2009. The
authors looked at all the recommendations and divided them into categories.
Out of 1167 total recommendations almost half (515) were categorized as medical
recommendations (Kunadharaju, Smith, & Dejoy, 2011). Within the medical recommendations
section, the three recommendations with the highest frequency were to 1) provide pre-placement
and annual medical evaluations consistent with NFPA, 2) phase in mandatory wellness and
fitness programs designed to reduce the risk factors of cardiovascular disease, and 3) perform
annual physical performance evaluations. The reason that OSHA’s emphasis on preventative
training and NIOSH’s recommendations on preventative training are pertinent is because these
are directly tied to issues regarding the Public Safety Officers Benefits Act (PSOB).
The PSOB was created in 1970 to provide the families of police officers, peace officers,
and firefighters with a federal death benefit payment and educational benefits for surviving
children in the event of a work-related death (Subchapter XI, Title 34 U.S.C.). Regarding
firefighters, this initially only included death by trauma such as fire, burns, or being hit by a car
while responding to an accident. However, in 2003, the PSOB was updated to include death by
heart attack and stroke as occupational-related deaths for firefighters. The update is significant
because OSHA mandates that employers educate and train their employees to reduce the risk of
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 43

occupational injury, illness, and death (OSHA, 2015). It should be of interest to NIOSH and
OSHA whether firefighters who die from heart attack or stroke on duty have received education
and training on how to prevent those causes of death, and what that training consisted of. As of
2017, the PSOB benefit was $350,079 for the surviving family and $1,041 per month for
educational assistance for full-time enrollment of the spouse and surviving children.
The IAFF, NFPA, NFFF, and the federal government all highlight the need for health and
wellness programs. Recommendations include initial and continuing education and training in
order to prevent workplace related injury, illness, and death (IAFF, 2008; Kunadharaju et al.,
2011; NFPA, 2012; NFPA 2015; NFFF, 2017; OSHA, 2015). The federal government also now
includes heart attack and stroke in their PSOB act as work related causes of death, which
suggests that at the very least, fire departments should educate firefighters on how to prevent
those.
The national level message is clear that initial and continuing health and wellness
education should be a focus of every fire department. However, it takes time for that message to
affect the fire service culture at the department level. The next section will review literature that
considers the fire service culture as it relates to health and wellness.
Fire Service Culture
Culture can take a long time to change. According to Clark and Estes (2008), it can take
up to 20 years before information gets adopted by a society. The IAFF-IAFC WFI began in 1997
(IAFF, 2008), which means cultural change should have occurred to some degree by 2017.
However, the fire service culture appears to need continued change efforts as demonstrated by
the current state of the average firefighter’s health (NFFF, 2016). This section will review
research specific to the culture and behavior of firefighters with regards to health and wellness.
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 44

A study conducted by Kay, Lund, Taylor and Herbold (2001) to look at disease-related
knowledge and behaviors found that most overweight firefighters did not believe they were in
fact overweight. Furthermore, firefighters that were identified as having abnormal cholesterol did
not have proper knowledge of how to control cholesterol (Kay et al., 2001). On the other hand,
79% of firefighters that were studied expressed a belief that their employer was not addressing
general health habits enough, and of those who expressed this belief, 97% wanted more health
information. The topics that were of greatest interest were nutrition, fitness, and stress
management. These three topics align very closely with the three major lifestyle health issues
affecting firefighters from Figure 3.
Staley’s (2008) dissertation findings suggested that the health culture of firefighters may
be influencing firefighters’ beliefs of what it means to be fit. Staley (2008) specifically focused
on firefighter health culture, fitness norms, and factors that facilitate fitness, and found that the
cultural meaning of firefighter fitness was whether one can do the work during an emergency
call. Firefighters in Staley’s research believed this, even if any or all of the physical fitness
metrics of an individual did not correlate with what is deemed to be appropriate for fitness.
Furthermore, Staley found that the firefighter fitness culture did not include cardiovascular
health as a reason to exercise and instead the reasons were usually to lose weight or gain muscle.
In 2011, Poston et al. looked at the prevalence of overweight, obesity, and substandard
fitness in male firefighters. They found that firefighters, controlling for age, were more
overweight and obese than the general population. Furthermore, the researchers wanted to
address a concern by firefighters that body mass index (BMI) was an inappropriate measurement
due to higher activity levels and perhaps higher muscle mass. In fact, false positives of obesity
classification using BMI were low, and false negatives using BMI were much more likely
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 45

(Poston et al., 2011). In other words, the BMI calculation more often underestimated a
firefighter’s weight than overestimated it. The study demonstrated that firefighters may lack
accurate weight perceptions.
Baur et al. (2012) also found that male career firefighter weight perception was
inaccurate. For overweight firefighters, a large majority did not perceive themselves to be
overweight. Furthermore, as weight increased into obese levels, even fewer firefighters had an
accurate weight perception. In the overweight category, only 32.4% correctly identified as
overweight, but in the obese category, only 8.2% correctly identified as being obese. On average,
the firefighters that did correctly identify as being obese were very close to being morbidly
obese. The authors suggested that weight perception may be dependent on group norms thus
altering what a normal weight or appearance is to the individual (Baur et al., 2012).
In 2013, a group of researchers set out to examine possible health and behavioral causes
of firefighter obesity. Dobson et al. (2013) found that five main themes accounted for the health
issues. The five themes were 1) station eating habits, 2) night calls and sleep disruption, 3)
supervisor leadership and physical fitness, 4) sedentary work, and 5) age and generational
influences. Large quantities of filling foods, high calorie snacking, and energy drinks are
considered normal for firefighters (Dobson et al., 2013). Firefighters mentioned that their station
officer’s lifestyle as well as group norms influenced their decisions. However, firefighters did
express an understanding that their jobs were becoming more sedentary which included a lot of
computer reporting and not a lot of physical activity.
In contrast to Dobson et al. (2013), Kuehl et al. (2013) conducted a study to see what
factors were responsible for the successful adoption of a fire department wellness program. To
do this the authors looked at a past study called Promoting Healthy Lifestyles: Alternative
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 46

models’ effects (PHLAME) (Moe et al., 2002). The PHLAME study was an effort to get fire
departments to adopt a wellness program. Kuehl et al. (2013) compared 12 departments that
successfully implemented a wellness program compared to 24 departments that did not. The
three main determinants were the informational mailer of the PHLAME study (70 departments
were initially sent a mailer, and many reported never seeing it), a firefighter that championed the
cause, and a chief that supported it. Of the departments that did successfully implement the
wellness program, the two main factors were the “champion” and the “chief” (Kuehl et al.,
2013). Having a wellness enthusiast that was passionate about the program regardless of position
or pay and a chief that was supportive of the program and the champion were critical to
implementation.
The national fire service organizations have been making an effort to spread the message
about necessary culture change as it relates to health and wellness (IAFF, 2008; NFFF, 2017;
NFPA, 2017). However, studies on the health and wellness culture of firefighters suggest a lack
of awareness and understanding of health issues and health norms (Baur et al., 2012; Dobson et
al., 2013; Kay et al., 2001; Poston et al., 2011; Staley, 2008). While leadership plays a role in
influencing firefighters at the station (Dobson et al., 2012; Staley, 2008), there seems to be a
cultural norm that is maintained by an overall lack of education on healthy lifestyle, healthy
eating, and risk factors of disease (Baur et al., 2012; Dobson et al., 2013; Kay et al., 2001;
Poston et al., 2011; Staley, 2008). Health and wellness education is being encouraged from the
national level but is lacking at the local level. The next section considers health and wellness
education at the state level, and the role that state training agencies play in fire service education.
Health and Wellness in the Fire Service at the State Level
The fire service is not a centralized national service. Fire departments are generally
funded and managed from local municipalities. However, some states fund training institutions
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 47

that offer training to career and volunteer firefighters. The training may range from required
initial qualification training, to advanced optional training. This section will review the findings
of a sample of fire service course curricula from eleven states, as well as the course curriculum
available in Maryland for career and volunteer firefighters.
Finding a Minimum Standard
National fire service organizations such as IAFF and NFFF address broad issues that
affect fire departments nationally (IAFF, 2017; NFFF, 2017). However, many firefighters rely on
training that is coordinated and delivered by their respective state fire training agency. As such,
state fire training agencies decide what training will be delivered to fire departments in the state.
A comparison between state fire training curricula could be done for all states which
would allow transparency as to which states are offering which courses and potentially showcase
certain states as models. It is not within the scope of this study to look at every state fire training
agency. However, a regional analysis was conducted for major states in the Mid-Atlantic and
New England regions. California, Texas, and Ohio were looked at independently due to their
political statuses as blue, red, and purple respectively (U.S. Archives, 2017). A model for
institutional curriculum comparison exists in a study conducted on medical schools in the U.S.
One researcher looked at medical school curricula to determine how many medical
schools were educating future doctors about exercise and physical activity. Most medical schools
(offering either a Medical Doctorate or Doctor of Osteopathy) offer no education on physical
activity or exercise, and when they did the courses were rarely required (Cardinal et al., 2015).
Surveys conducted among physicians and medical students showed a low confidence level in
their knowledge and skills in prescribing physical exercise or advice. The research was a direct
challenge to a national medical initiative called the Exercise is Medicine Initiative.
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 48

With lifestyle illnesses of heart attack, suicide, and cancer so strongly affecting
firefighters (IAFF, 2008; NFPA, 2017; Soteriades, 2011), perhaps it is time to consider adding
physical and behavioral health and wellness courses into the fire academy and continuing
education curricula. The following section reports on a review of the curricula available to
firefighters from the National Fire Academy (NFA), as well as other state fire training agencies.
It then reviews Maryland Fire and Rescue Institute (MFRI) as an example of a state fire training
agency.
Review of Regional Fire Service Course Offerings
The National Fire Academy (NFA) publishes their training courses online, as do many
state fire training agencies. A look at the NFA curriculum and a sampling of states around the
nation revealed a similar lack of health and wellness courses. Course curricula catalogues were
analyzed for the NFA and eight states in the Mid-Atlantic and New England regions (VA, MD,
PA, DE, NJ, NY, MA, CT) using the curricula available on the training agency’s website. Course
curricula from three additional states (CA, OH, and TX) were also included. California, Ohio,
and Texas were included because they span the political spectrum (U.S. Archives, 2017) and fall
within the top five states for firefighter employment according to the Bureau of Labor Statistics
(BLS, 2017). As of 2018, over 80% (9 out of 11) of these training agencies did not offer
preventive education for firefighters on lifestyle illnesses. Based on the data from the Bureau of
Labor Statistics, the nine states that did not offer health and wellness education have 110,000 of
the 315,000 career firefighters in the United States, which does not include volunteers (BLS,
2017). There are roughly three volunteers for each career firefighter in the United States.
The NFA advertised two online courses. The first course “Empowering Responder
Wellness U0381” advertised to be about personal health and lifestyle, however there were no
details about the course or how many hours it was (U.S. Fire Administration, 2017). There was
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 49

also a course titled “Department Wellness Program O0144” which teaches fire officers how to
start a wellness program but not about preventing lifestyle illness (U.S. Fire Administration,
2017).
Massachusetts and New Jersey were the only two out of the sample of 11 states to offer
coursework that appeared to be directly related to educating firefighters on reducing risk of
physical or behavioral health issues. Massachusetts offered one course and New Jersey offered
three courses. Ohio, New Jersey, and Virginia all offered a course from NFFF called Stress First
Aid. However, this course was intended to teach firefighters how to respond to a peer who is in
emotional distress and was not intended to teach firefighters how to prevent or manage emotional
stress in themselves. Additionally, Maryland Fire and Rescue Institute (MFRI) offered a course
like the NFA called Department Wellness Coordinator. However, this course was designed to
teach fire officers how to begin a wellness program.
Based on the review of state fire training course catalogues it appeared rare for a state fire
training agency to offer a course on preventing or managing physical or behavioral wellness
issues. Career and volunteer firefighters in Maryland rely heavily on the state training agency for
free courses. Because HCFR is in Maryland, the next section will use MFRI as an example to
look at the stated purpose of a state fire training agency as well as the funding for that agency.
State Fire Training Example
In a statement to the government of Philadelphia regarding a more prepared fire service,
Benjamin Franklin said that “an ounce of prevention is worth a pound of cure” (Ringwall, 2017,
p. 1). Ironically, that same quote could be used today for health and wellness in the fire service.
The idea of training workers as OSHA sees it must include efforts to reduce or eliminate the risk
of illness, injury, or death related to work (OSHA, 2015).
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 50

MFRI is the state training agency for Maryland and is affiliated with the University of
Maryland, College Park. As MFRI stated on its website, it exists to be a comprehensive
education and training system that plans, develops, and delivers courses to career and volunteer
emergency service providers to better help them do their job. The State of Maryland’s legislature
grants MFRI the authority to carry out this charge both on campus and across the state which
allows for MFRI to partner with other agencies as well as to adopt materials that may be
pertinent (MFRI, 2017).
State fire training agencies are vital resources for Maryland first responders. MFRI
acknowledges on its website how important education and training are to preventing injury and
loss of life as well as to the successful preparation of responders. Furthermore, MFRI explains
how it has adapted to the needs of the fire service over time and can quickly develop new course
material if needed (MFRI, 2017). However, as of 2017, MFRI offered no preventive health or
wellness courses for firefighters in their course catalogue (MFRI, 2017). There is a cost
associated with education and training and as such MFRI is funded by the State of Maryland. For
fiscal year 2018, MFRI received $8.8 million, an increase from $8.6 million in 2017, and $ 8.1
million in 2016. The source of this revenue comes from state taxes (FY 18 Maryland State
Budget, 2017).
MFRI stated on its website that it is proud of its ability to meet the needs of its customers
which are first responder departments throughout Maryland (MFRI, 2017). The next section will
look at Howard County Fire and Rescue (HCFR) as an example of a local fire department within
Maryland that is one of MFRI customers. The overview of HCFR is presented based on the
researcher’s familiarity of the department as a currently serving professional firefighter (since
2008), as well as knowledge based on content specific literature.
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 51

Health and Wellness in the Fire Service at the Local Level: Howard County, MD
The state of Maryland has 24 counties and extends from the Appalachian Mountains in
the western end of the state, to the Atlantic Ocean on the eastern end. Some areas of Maryland
are very rural, and others are densely populated resulting in a range of operational diversity for
the fire departments in different counties. Howard County is located in between Washington, DC
and Baltimore, MD. The counties in Maryland that surround Washington, DC and the city of
Baltimore are densely populated. Because of the dense population and higher call volume, many
counties in central Maryland rely on career firefighters. Howard County Fire and Rescue uses
both career and volunteer firefighters. The following section will explore Howard County Fire
and Rescue’s organizational structure, standards, and support regarding health and wellness.
Organizational Structure
Howard County Fire and Rescue (HCFR) is a municipal public safety agency responsible
for all-hazards emergency response. HCFR serves 350,000 citizens over 253 square miles
between Washington, D.C. and Baltimore, MD. HCFR has roughly 500 career firefighters and a
similar number of volunteers, 12 fire stations, and an operating budget of roughly $100 million
(Howard County Government Budget, 2018).
Initial education. Howard County Fire and Rescue conducts a six-month (26 weeks)
training academy for its new recruits (Howard County Fire and Rescue, 2017). Most classes in
the academy are MFRI designed and certified courses. After graduation from the academy,
recruits receive MFRI certificates for the MFRI courses that they took. The recruits are then
expected to complete a number of training assignments from a “rookie-book” over the course of
their probationary year. Currently, MFRI does not offer any health and wellness courses and
HCFR does not have a health and wellness educational component of its recruit academy.
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 52

Continuing education. Firefighters in HCFR are mandated to take certain continuing
education courses and given the option for others. For example, firefighters in HCFR must
maintain their Emergency Medical Technician (EMT) certificate for employment and these
courses are offered and paid for by HCFR. Other courses that are considered professional
development, such as fire officer courses, are not mandatory, but may be needed for promotion.
Much of the continuing education coursework that HCFR offers are developed and funded by
MFRI. At the time of research there were no health and wellness courses offered by MFRI.
Bureau of Occupational Safety and Health. Howard County Fire and Rescue
announced the addition of BOSH as its newest Bureau in 2014. BOSH is charged with 1)
overseeing the department’s policy creation, 2) prevention and response efforts, and 3) day to
day management of firefighter safety, health, and wellness initiatives. Since its inception, BOSH
has been working to implement initiatives for all of its responsibilities. Four firefighters and two
civilians are assigned to BOSH on a full-time basis. Additionally, there is a peer fitness team
(HCFR General Order 150.13) focused on physical health and a peer support team (HCFR
General Order 100.19) focused on behavioral health, that are made up of firefighters from across
the department.
Organizational Standards
Promotional process. Howard County Fire and Rescue requires firefighters to complete
designated coursework for each promotional level. For instance, to promote from firefighter to
lieutenant, a firefighter must first have completed 13 courses (most of which are MFRI courses),
45 semester hours of college from an accredited institution, and have at least four years of
experience after the probationary year has finished (HCFR General Order 100.04). Furthermore,
there is an Officer Candidate School that firefighters on the promotional list attend before
promotion. However, none of the courses required for promotion to lieutenant, or any higher-
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 53

level position, include health and wellness education. Officer Candidate School has no health
and wellness education component (HCFR OCS Course Schedule, 2017).
Annual evaluations. Howard County Fire and Rescue currently conducts medical
evaluations for each of its career firefighters. It is working with volunteer fire corporations
within Howard County to ensure 100% of volunteers receive a yearly medical evaluation as well.
The medical evaluations include a comprehensive screening by an occupational health doctor on
vision, hearing, lung capacity, blood work, health metrics, and a cardiovascular stress test.
In 2017, HCFR launched a new annual firefighter fitness initiative called Response Fit.
This initiative made it mandatory for firefighters to report to the academy to receive a
presentation on Response Fit. Participation in the course was voluntary. Currently HCFR has no
weight standards to maintain employment as a firefighter. However, weight, body mass index,
and body fat levels are recorded annually at firefighters’ medical evaluations.
Day-to-day expectations. While each station in a fire department is slightly different
depending on the location, there are many things that are similar (Staley, 2008). Firefighter
station life includes responding to calls, keeping the station and equipment clean and ready, and
training activities. In HCFR, firefighters have access to a gym at every fire station. However,
there are no mandatory fitness requirements. Firefighters often prepare meals together and eat
together. However, there are no nutritional guidelines or classes for firefighters. The shift
schedule at HCFR is a 24-hour on and 48-hour off cycle. Firefighters can sleep at night if there
are no calls.
Organizational Support
Howard County Fire and Rescue offers support for its firefighters in a variety of ways.
HCFR has firefighter fitness trainers who are certified through the American Council on
Exercise (ACE) as certified personal trainers. Those firefighters have met the minimum required
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 54

training to provide individual fitness training and coaching. PFT training is a start and is not
meant to signify expertise in physical health and wellness knowledge or even fitness knowledge.
The fitness trainers in HCFR have been used mostly for helping with the hiring process of
academy classes. Currently BOSH is working on developing a system for firefighters to request
and meet with a trainer. HCFR also maintains a peer support team program. This program is
made of firefighters who are trained through the International Critical Incident Stress Foundation
(ICISF) and NFFF. Those firefighters have met the minimum required training determined by
BOSH to serve as peer support team members. The firefighters on the peer support team offer
behavioral health peer support during times of crisis. PST training is a start is not meant to
signify expertise in behavioral health and wellness knowledge. Currently BOSH is working on
developing a system for firefighters to request a peer support team member for non-crisis support
and education on available resources.
HCFR has two other major support programs. Firefighters have access to an employee
assistance program (EAP) through the county government. The employee assistance program
allows firefighters to seek help for a wide variety of life issues including addiction, marital
issues, financial issues, and others. The other major support program is tuition reimbursement.
Firefighters can receive up to $1,500 a year towards coursework that is applicable to the
department and can be counted toward a degree. All of the benefits mentioned above are self-
selected by the firefighter and therefore serve as responsive and not proactive support services.
One of BOSH’s organizational goals is to develop an initial and continuing health and
wellness curriculum for HCFR. BOSH could potentially work with MFRI or other fire service
organizations to have any coursework that is developed adopted for dissemination to other fire
departments throughout Maryland or even the United States. This research will be seeking to
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 55

understand what knowledge, motivation, and organization influences are necessary for BOSH to
develop an initial and continuing health and wellness educational curriculum.
BOSH Knowledge, Motivation, and Organizational Influences
The Clark and Estes (2008) framework is suited to study stakeholder performance within
an organization. Clark and Estes’ problem-solving process is based on two main points. The first
is understanding the context of the stakeholder goal and the organizational goal and making sure
they are aligned properly. The second is identifying the areas of knowledge, motivation, and
organization that may be hindering the stakeholder goal from being met. This process includes
researching related theory, context specific literature, and obtaining an understanding of the
organization being considered. The following section includes the BOSH stakeholder group’s
specific knowledge, motivation, and organization influences as they relate to health and wellness
education for HCFR.
Knowledge and Skills’ Influences
Knowledge, motivation, and organizational influence are three factors that can hinder or
enhance performance within an organization (Clark & Estes, 2008). These three factors apply to
an organization in a similar way that four factors apply to an individual according to Aristotle.
Twenty-five hundred years ago, Aristotle concluded that individual responsibility is determined
by analyzing four areas: knowledge of the circumstances, knowledge of right and wrong,
intention, and the ability to do otherwise (Nicomachean Ethics). Without any one of those four
factors in place, an individual cannot be held fully responsible for their accomplishments or
failures.
Similarly, knowledge, motivation, and organizational factors are linked to the success or
failure of an organization. Clark and Estes (2008) expect that the organizational leader has
identified the circumstances and goals of their organization. The circumstances dictate what can
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 56

be changed and what cannot be changed. Clark and Estes (2008) explain that knowledge is
necessary when individuals or organizations are responsible for carrying out a goal. Therefore,
knowledge as it relates to KMO refers to whether stakeholders will act in the right or wrong way
regarding organizational factors that can be changed. For BOSH, the goal is to provide initial and
continuing health and wellness education applicable to 100% of HCFR members.
The National Fire Protection Association (NFPA) has industry standards for health and
wellness (NFPA 1500; NFPA 1583). Heart attack is the number one cause of firefighter on-duty
death, and has been so for decades (NFPA, 2016). Furthermore, suicide and cancer deaths far
outnumber the on-duty heart attack deaths for firefighters (NFPA, 2017). However, 70% of fire
departments have no access to health and wellness programs (NFPA, 2016b), and it is not clear if
the 30% of departments that do have programs include initial academy or continuing education.
HCFR currently has no established initial or continuing health and wellness education for its
firefighters.
Change can only occur when there is learning of new knowledge and skill (Alexander,
Schallert & Reynolds, 2009; Grossman & Salas, 2011; Mayer, 2011). Moreover, learning new
knowledge and skill provides individuals and organizations considerable gains in understanding,
behavior change, and performance (Aguinis, & Kraiger, 2009; Clark & Estes, 2008; Grossman &
Salas, 2011). Without any education being delivered to firefighters on how to prevent heart
attack, suicide, or cancer, there can be no expectation that culture will change for the better.
However, education must go beyond presenting information, and must include an opportunity for
students to demonstrate their understanding and be given feedback through assessment (Clark,
Yates, Early, & Moulton, 2010). Furthermore, the information must go beyond factual
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 57

knowledge and include other types of knowledge which are critical for understanding a subject
(Clark et al., 2008).
Knowledge types. There are four types of knowledge: factual, conceptual, procedural,
and metacognitive (Clark & Estes, 2008; Krathwohl, 2010; Mayer, 2011). Factual knowledge is
the “what”; conceptual knowledge is the “why”; procedural knowledge is the “how”; and meta-
cognitive knowledge is the understanding of self (Krathwohl, 2010). The fire service has facts
and data about what is killing firefighters (NFPA, 2017). However, knowing just the facts are not
enough to achieve the organizational goal or stakeholder goal for BOSH.
Both content and pedagogical knowledge are necessary for effective teaching (Ball,
Thames, & Phelps, 2008; Even, 1993; Ferguson, & Womack, 1993; Guyton, & Farokhi, 1987).
To develop a health and wellness curriculum for firefighters, it is necessary to have a thorough
understanding of content knowledge of how to prevent heart attack, suicide, and cancer, as well
as pedagogical knowledge. The following two sections will explore the knowledge influences of
subject content, and pedagogy, as well as the knowledge types that apply to each influence and
why they are critical for achieving the stakeholder goal of BOSH.
Content knowledge for health and wellness. Content knowledge is the deep
understanding of a subject, beyond merely facts and data (Ball, Thames, & Phelps, 2008).
Anyone can click through a PowerPoint and read what is on the slides, and anyone can Google
search for information and begin the process of inquiry. With the advent of internet search, a
myth developed that learners know best and can effectively navigate and identify trustworthy
information (Kirschner & Merrienboer, 2013). However, when a student conducts self-inquiry
while having a low knowledge of subject matter, the ability for the student to retrieve and
understand the knowledge available is greatly hampered (Clark et al., 2010; Kirschner &
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 58

Merrienboer, 2013). Furthermore, learners have shown they will often choose what they prefer,
but what they prefer is not always what they need (Kirchner & Merrienboer, 2013). Therefore, a
teacher should have appropriate content knowledge at the conceptual level in order to provide
learners with a foundation that can help guide self-inquiry.
The purpose of education is to give learners the knowledge and skills that will aid them in
handling new challenges or problems (Clark & Estes, 2008). For learners to engage in critical
thinking and overcome novel challenges, they must understand why something is the way it is,
not just what it is, or how to use it (Ball, Thames, & Phelps, 2008; Clark & Estes, 2008). As
stated by Ball et al. (2008), a teacher with command over the content knowledge understands
how it applies horizontally as well as vertically. In other words, a teacher should know where
and how their content is related to content in other curricula, as well as how it applies to what the
learner has been taught and what will be taught (Ball et al., 2008).
The fire academy is the primary educational conduit in HCFR. Fire recruits spend six
months there before going out to the field, and it is in the academy that firefighters engage in
new challenges, deepen their understanding of content, engage in application of that knowledge,
and are given feedback on their application. BOSH must have the content knowledge of
preventing heart attack, suicide, and cancer at the conceptual level in order to effectively instruct
firefighters at that level. Successful instruction at the conceptual level of health and wellness
includes firefighters being able to think critically about their wellness choices and connecting
wellness to their careers and to their lives. However, commanding the content of a subject is not
easy, and does not happen fast. It takes on average 10,000 hours of dedicated and deliberate
practice, with the aim of continual and expanding knowledge and skill to become an expert
(Ericsson, 2012; Ericsson, Krampe & Tesch-Romer, 1993; Kahneman, 2011; Rueda, 2011).
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 59

Experts seek out and engage in new experiences that are deliberately chosen to enhance
their command of a domain (Dyer, Gregersen, & Christensen, 2013; Rueda, 2011). This
continual growth process gives experts the ability to use their knowledge and skills to adapt to
changes or create new ways of doing something (Rueda, 2011). Dyer et al. (2013) offer the
following five practices that support a deliberate growth strategy: observation, networking,
questioning, experimenting, and associating. Associating is the process of fusing together diverse
knowledge, skills, and experiences to produce innovative thought, products, or processes.
However, becoming an expert requires at least two additional factors. The first is interest.
Interest in a subject greatly affects the amount of deliberate practice one devotes to gaining the
appropriate knowledge and skill (Greene, 2012; Schraw & Lehman, 2009). The second is
feedback. Honest feedback is critical in the development of knowledge, ideas, and processes
(Catmull & Wallace, 2014; Shute 2008).
Pedagogical knowledge for health and wellness. Pedagogical knowledge is more than
just being able to speak in front of a class. Pedagogical knowledge is the understanding of
theory, approaches, and practices that help to instill lasting change in the way a learner behaves
physically, psychologically, and socially (Alexander, Shallert, & Reynolds, 2009). Consequently,
learning should involve more than just reciting facts or ideas (Alexander et al., 2009; Krathwohl,
2002).
The instructor should be working to improve learner comprehension, and pedagogical
knowledge supports those efforts (Ball et al., 2008; Even, 1993). If content knowledge is the
program being installed into the student, then pedagogical knowledge is the process of installing
the program. The relationship between these two knowledge influences is critical. An instructor
with content knowledge alone but without pedagogical knowledge is less effective at providing
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 60

proper education (Ferguson & Womack, 1993; Guyton & Farokhi, 1987). Therefore, procedural
knowledge of how to use effective pedagogy is necessary for instructors to design and deliver
curriculum that will have a lasting impact on learners.
Clark (2004) explains that proper lesson design and delivery should consist of seven
steps: Objectives; Reasons for learning; Overview; Conceptual knowledge; Demonstration; Part
and whole-task practice, and; Challenging, competency-based assessment. In this seven-step
process, the first four steps are part of an initial process to share information with the learner.
The fifth and sixth steps are the transition from abstract understanding, to the application of that
understanding. The final step determines if knowledge transfer took place.
Curriculum design is a key component in education. Course materials and tasks should be
user friendly, clear and coherent (Schraw & Lehman, 2009). Dry PowerPoint presentations and
ideas that are too abstract can hinder student focus. However, choosing materials and tasks that
are related to real-life experiences and are diverse, new, and challenging but doable promote
learning and mastery orientation (Pintrich, 2003; Schraw & Lehman, 2009; Young & Anderman,
2006). The course designer should also consider other learning that the students have had or will
encounter; this helps students make meaningful connections between new knowledge and prior
knowledge (Ball et al., 2008; Schraw & McCrudden, 2006). With proper pedagogical
knowledge, BOSH can make health and wellness interesting, applicable, meaningful, and
memorable. However, BOSH must also be able to know if knowledge transfer occurred.
In order to make those meaningful connections last a long time, knowledge transfer
practices must be incorporated (Grossman & Salas, 2011). Testing is a simple and immediate
way to aid knowledge transfer (Carpenter, 2012), but not the only way. More complex transfer
practices rely on meaningful connections between learners and their instructors, whether
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 61

supervisor or peer (Martin, 2010). Guided practice and feedback are two effective ways of
enhancing knowledge transfer through meaningful relationships. These transfer practices must be
deliberately built into an educational program; they are not automatic.
To build in knowledge transfer practices, educators should provide learners with the
ability to practice what they learned. Academy instructors are tasked with guiding firefighters
during the six-month fire academy at HCFR. Allowing learners to explore skill development,
integrate those skills into their work, and make errors while under a supervisor’s instruction
supports the knowledge transfer process (Grossman & Salas, 2011; Schraw & McCrudden,
2006). Learners also need appropriate feedback during and after assessments. Feedback can be
written or verbal and both help the learner understand their development towards mastery
(Catmull & Wallace, 2014; Martin, 2010). Proper feedback is targeted, timely, private, and
includes improvement strategies (Grossman & Salas, 2011; Martin, 2010; Shute, 2008).
Curriculum design, meaningful connections, guided practice, and proper feedback are all
examples of effective procedural knowledge of pedagogy. Curriculum design should include
three major areas of information delivery, an opportunity to practice what was learned, and a
challenging assessment (Clark, 2004). HCFR has a peer support network of certified fitness
trainers that are available to provide guided practice and feedback. However, currently there is
no initial or continuing health and wellness education for firefighters, so peer fitness trainers
have no foundation to use for guided practice and feedback. Table 2 provides information
specific to knowledge influences, knowledge types, and knowledge influence assessments. As
Table 2 indicates, an assessment will be used to gain insight about the content knowledge and
pedagogical knowledge that BOSH possesses or needs to possess.
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 62

Table 2
Knowledge Influences, Types, and Assessments for Knowledge Gap Analysis
Knowledge Influence Knowledge Type
Knowledge Influence
Assessment
BOSH needs to have the
content knowledge of
physical and behavioral
health and wellness issues
that affect firefighters
Conceptual
Interview:
What H/W issues are the most
critical for firefighters?
What are some ways to prevent
the major H/W issues?
BOSH needs to
understand effective
pedagogy
Procedural
Interview:
What is needed to conduct
effective education?
What is needed to be an effective
instructor?

Motivation Influences
Motivation is the second of the three factors (knowledge, motivation, and organization)
that relate to organizational success or failure (Clark & Estes, 2008). Motivation can be
abstracted from the individual to the organization. Aristotle stated that an individual can only be
held fully accountable for an act if they intended, with free will, to carry out the action
(Nicomachean Ethics). Likewise, Clark and Estes (2008) stated that when assessing
organizational performance, intention is needed to pursue a goal. However, intention must be
followed by active choice to begin a task, and persistence to continue it (Clark and Estes, 2008).
Therefore, the implementation of a program indicates that an active choice and some degree of
persistence has already occurred (Clark & Estes, 2008; Mayer, 2011).
The very existence of BOSH is the representation of organizational interest in health and
wellness. However, HCFR did not have an initial or continuing educational curriculum for
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 63

physical or behavioral health and wellness. For measuring motivation in the future, it will be
important to assess not only BOSH's beliefs and intent regarding health and wellness education,
but also active choices. However, since there was no health and wellness education, this research
only focused on intent and beliefs. The assessment helped to clarify whether it was BOSH
stakeholders or organizational factors that may have been responsible for the lack of initial and
continuing health and wellness education in HCFR. Motivational assessments included whether
BOSH perceived education on health and wellness as valuable, and whether BOSH believed that
it can attribute positive change in firefighters to education that it develops and delivers. The
following sections will thus consider utility value and attribution theory as they relate to BOSH.
Utility value theory. Utility value is one of four constructs to expectancy value
motivational theory (Eccles, 2009). The three other constructs are intrinsic interest, attainment
value, and perceived cost (Eccles, 2009). Intrinsic interest represents fulfillment in doing a task
and attainment represents how closely aligned the task is to one's identity (Eccles, 2009). If
BOSH develops and maintains a health and wellness curriculum for HCFR, the intrinsic and
attainment value will be included into the process because health and wellness promotion is part
of BOSH's reason for existence. Perceived cost is important to consider and can include money,
time, energy, and social or political reactions (Eccless, 2009). However, cost is secondary to
whether or not BOSH finds utility value in creating and maintaining health and wellness
education.
BOSH utility value of health and wellness education. Utility value is a measure of how
well a task fits into long-term goals (Eccles, 2009; Pintrich, 2003). The long-term goals of BOSH
are reflected in its mission statement which is to foster safety, wellness, and health in HCFR. To
do this, BOSH must constantly work to prevent injury, illness, and death through education of
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 64

HCFR. Clark and Estes (2008) argued that education is the foundation for initiating change and
maintaining change.
Public organizations are accountable for, and as such find value in, the proper
management of finances, legal issues, and human resources (Dubnick, 2014; Wallis & Gregory,
2009). BOSH is interested in reducing the costs and risks of illness and injury and optimizing
human performance. The top three health and wellness issues for firefighters are heart attack,
suicide, and cancer (NFPA, 2017). Therefore, preventing these three events are of specific value
to BOSH. However, preventing these events involves addressing the underlying health issues
that lead them. Preventable lifestyle factors are prevalent in heart attacks (Kales, et al., 2007;
Kunadharaju et al., 2011; Soteriades et al., 2011), suicide (Cavanagh, Carson, Sharpe & Lawrie,
2003; Harris & Barraclough, 1997; Henderson et al., 2016), and cancer (Anand et al., 2008;
Carroll, 1998, Larsson & Masucci, 2016; Seyfried, 2014).
Not only do lifestyle factors contribute to the top three health and wellness issues for
firefighters, they also contribute to direct and indirect costs to employers. For instance, obesity
can cost an employer as much as $2400 a year per employee in lost productivity and other costs
(Finkelstein, Feibelkorn & Wang, 2005; Trogdon, Finkelstein, Hylands, Dellea & Kamal-Bahl,
2008). Behavioral health issues are similarly costly to employers and can be as high as $1600 a
year per employee (Johnston, Westerfield, Momin, Phillippi & Naidoo, 2009). Approximately
35%- 45% of firefighters are obese (NFFF, 2016), and HCFR has roughly 500 career personnel.
If HCFR has 165 obese firefighters (33%), and if the average cost of lost productivity was
applied to those firefighters, the costs to the department could be as high as $396,000 a year.
However, in the case of HCFR and other fire departments, the goal is not to make money, so
productivity would be much harder to calculate. In contrast, Baicker, Culter and Song (2010)
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 65

argued that employers can see a return on investment of roughly $3 for every $1 spent on
wellness initiatives.
HCFR could also be held accountable for providing proper health and wellness education
for firefighters. The Occupational Safety and Health Administration (OSHA) mandates
industries provide education and training to the workforce to reduce job related risks (OSHA,
2105). There are also industry standards that call for health and wellness education (NFPA 1500;
NFPA 1583). The second most frequent recommendation from the National Institute of
Occupational Safety and Health (NIOSH), in regard to firefighter line-of-duty deaths, is the
implementation of mandatory wellness and fitness programs (Kunadharaju et al., 2011).
Therefore, it is in the interest of HCFR to provide health and wellness education on issues that
are, or may be, linked to firefighting.
In sum, an investment by HCFR in health and wellness is an investment in its employees
as well as in its organization. Health and wellness initiatives bring higher productivity, lower
absenteeism, and reduced medical costs (Baicker, Cutler, & Song, 2010; Pronk, 2014).
Furthermore, employers with good health and wellness initiatives can benefit from higher
recruitment and retention rates, higher job satisfaction, better worker cohesion, and improved
employee engagement (Pronk, 2014). Therefore, understanding if BOSH finds utility value in
health and wellness education is critical to understanding BOSH’s ability to achieve its goals.
Attribution theory. Attribution theory is focused on understanding how individuals or
organizations frame the cause associated with an effect in their environment (Anderman &
Anderman, 2006). Based on the belief of what is causing a specific effect, an individual or
organization may conclude that they have more or less control of their environment (Anderman
& Anderman, 2006). As an example, educators believe that their effort at teaching can improve
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 66

the knowledge of the learner. Consequently, when an individual believes they have control over
a task outcome their motivation to engage in that task increases (Anderman & Anderman, 2006).
The next section will highlight literature relevant to attributing control of health and wellness
outcomes to BOSH.
BOSH attributions for firefighter health and wellness. Heart attack on duty for
firefighters has been linked to emergency response activities (Kales et al., 2007; Smith, 2008).
Furthermore, the Public Safety Officers Benefits Act (PSOB) awards firefighter’s families a tax-
free federal death benefit of $350,079 which, as of 2003, includes deaths from heart attack and
stroke (NFPA, 2016). It would be understandable for a fire department to be content with the
belief that heart attacks are just part of the job. However, on-duty heart attacks in firefighters are
largely related to preventable lifestyle issues (Kales et al., 2007; Kunadharaju et al., 2011;
Soteriades et al., 2011).
Preventing heart attacks and the related lifestyle issues that lead up to them will require
education and training of firefighters. Not only are employers mandated to provide education and
training for work related risk factors (OSHA, 2015), but NFPA and NIOSH have both repeatedly
called for health and wellness education programs (Kunadharaju et al., 2011; NFPA 1500; NFPA
1583). Fortunately, knowledge and performance can improve from proper education and training
(Aguinis & Kraiger, 2009; Anderman & Anderman, 2009; Pajares, 2006). Furthermore, there is
extensive research on successful physical-health related interventions in firefighters (Banes,
2014; Elliot et al., 2007; McDonough, Phillips, & Twilbeck, 2015). Behavioral health can also
improve with proper training (Ratey & Hagerman, 2008; Smith et al., 2011; Wagner, & Martin,
2012).
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 67

When considering whether to invest in education and training, it is important to
acknowledge differences in cognitive ability and the role that IQ plays in learning (Alexander, et
al., 2009; Hernstein & Murrary, 1994; Kirschner & Merrienboer, 2013; Pashler, Mcdaniel,
Rohrer, & Bjork, 2008). However, in the case of HCFR, a civil service test (which evaluates
cognitive ability) and a psychological evaluation are conducted. Therefore, while there will
surely be differences within the ranks, BOSH should be confident that the firefighters within
HCFR have demonstrated a minimum standard of cognitive ability necessary to succeed in the
profession. Anderman and Anderman (2009) stated that when the ability is there for the given
task, success or failure depends, at least in part, on effort; this can include the effort of the
learner or the educator. An educator who does not believe they can create change in a learner
will not give much effort. Therefore, it is critical to the research to understand if BOSH
stakeholders believe they can create change through education. Table 3 identifies two
motivational influences: utility value, and attribution. These influences will be used to more fully
understand how motivation affects BOSH’s desire to conduct health and wellness education for
HCFR.
Table 3

Motivational Influences and Assessments for Motivation Gap Analysis
Assumed Motivation Influences Motivational Influence Assessment
Utility Value - BOSH needs to see the
value in educating firefighters about
health and wellness at the beginning,
and throughout their careers for both
the individual and the organization.
Survey item: Educating firefighters about physical and
behavioral health and wellness in the academy should be
a priority for HCFR. (Strongly disagree-strongly agree)
Interview item: What role does initial, and continuing
education play in regard to H/W for firefighters?
Attribution - BOSH needs to
understand that firefighter health and
Survey item: BOSH is capable of improving HCFR
firefighters’ health and wellness through education.
(strongly disagree-strongly agree)
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 68

wellness can be changed through
BOSH’s educational efforts.
Interview item: What is BOSH's role in firefighter
health and wellness?

Organizational Influences
General theory. Organization is the last of the three factors that relate to organizational
success or failure (Clark & Estes, 2008). Aristotle argued that on an individual level,
responsibility for success or failure is determined by one’s ability to do otherwise (Nicomachean
Ethics). In other words, there may be external factors outside of one’s control so that an action
could not occur. A stakeholder’s ability to do otherwise may be impacted by organizational
culture or settings.
Organizational culture is a term that is used to describe the characteristics, values, and
beliefs of a group (Clark & Estes, 2008). Groups and organizations are made up of individuals
and therefore the culture of a group is a mixture of characteristics of those in the group (Clark &
Estes, 2008; Erez & Gati, 2004). This invisible mixture of individual characteristics, values, and
beliefs is what Gallimore and Goldenberg (2001) call a cultural model.
The cultural model of an organization is often taken for granted as standard operational or
procedural practices (Gallimore & Goldenberg, 2001). However, once an organizational culture
is in place, that culture can affect the individuals within it (Gallimore & Goldenberg, 2001), as
well as the environment around the organization (Erez & Gati, 2004). The effect that a culture
has on individuals is strong and can be long lasting (Kezar, 2001). Organizational resistance to
change can be likened to the principle of inertia. Once an object is in motion it tends to stay in
motion on a path, unless a strong enough force changes it. Organizational culture and more
specifically, cultural models, are the inertia of the group norms, understandings, and behaviors
that are in place, and these models can affect cultural settings.
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 69

The cultural settings of an organization are behaviors in practice that one can see, and
that affect the way an organization operates on a day to day basis (Gallimore & Goldenberg,
2001). Cultural settings may be the policies in place, the structure of an organization, or perhaps
the training processes one must go through in their position but can also be the lack of such
things. Gallimore and Goldenberg (2001) give the example of bed time stories as a cultural
setting in the home. If the cultural model is inertia, then the cultural settings are the attributes of
the environment that an object changes (or not) as it continues in its path. Indeed, Schein (2004)
refers to the attributes as artifacts, which is how he makes sense of cultural settings. The
following section explores the cultural models and settings that are factors of organizational
influence on BOSH.
BOSH specific factors for a culture of health and wellness. The fire service is part of
the first responder community. Firefighters train and prepare to respond to emergencies, manage
those emergencies, and in the process, save lives and property. While fire departments have the
authority to conduct preventive safety inspections and often work hand-in-hand with their local
government to review building permits, these responsibilities are often conducted by inspectors
and fire marshals (IFSTA, 2007). However, the firefighter at the station is most immediately
concerned with response (IFSTA, 2007). Therefore, while there are prevention efforts in the fire
service, the underlying culture, indeed the descriptive word used, is that of responding.
There is a response culture of the fire service (Dobson et al., 2013). Because of this
culture, initiatives may not be implemented until a department feels obligated to act in response
to an event. The IAFF/IAFC WFI developed the peer fitness trainer model and the peer support
team model (IAFF, 2008) to address firefighter health issues. Additionally, the WFI, NFFF, and
NFPA call for education and training for health and wellness (IAFF, 2008; NFFF, 2017; NFPA,
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 70

2012; NFPA, 2015). However, HCFR does not have initial or continuing health and wellness
education.
The fact that heart attack, suicide, and cancer have such a high profile for the fire service
(IAFF, 2008; NFFF, 2016; NFPA, 2017) suggests that the culture of health and wellness needs
improvement. The NFFF is actively involved in trying to change the culture of the fire service
which is the number one priority of its 16 Life Safety Initiatives (NFFF, 2017). Although the
word “wellness” is not included, the NFFF 16 life safety initiatives include safety, health, fitness,
and psychological support as priorities. This research seeks to understand the current health and
wellness culture of HCFR and BOSH.
BOSH authority to implement health and wellness education. BOSH was created in
2014 as the bureau that oversees initiatives on safety, health, and wellness in HCFR. As such,
BOSH should be held accountable for its successes and failures. Being accountable includes
identifying the responsible party, delegating to that party the authority to act, and identifying the
specific contract of duty (Dubnick, 2014; Emmanuel and Emmanuel, 1996). BOSH has already
been created as a bureau, and given a mission to oversee safety, health, and wellness, and thus
has a responsibility to act and a contract of duty. However, BOSH cannot be fully accountable
for an outcome if it is lacking authority. Therefore, the first influence that needs to be assessed is
whether BOSH has authority to implement health and wellness education into current programs
in HCFR, such as the 26-week fire academy.
BOSH resources to implement health and wellness education. Resources refer to the
money, human capital, and other administrative support necessary to complete an initiative
(Robins & Judge, 2010). According to Waters, Marzano, and McNulty (2003) organizational
effectiveness increases when leaders insure that employees have the resources needed to achieve
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the organization’s goals. BOSH needs to be funded and staffed appropriately for developing and
implementing health and wellness education. Therefore, the second influence that needs to be
assessed is whether BOSH receives adequate funding and staffing resources.
BOSH support from the fire chief and a champion. Kuehl et al. (2013) identified two
main factors which included having a wellness enthusiast that was passionate about the program
regardless of position or pay and a chief that was supportive of the program and the champion.
BOSH needs to have support from the fire chief, as well as one or more wellness champions
willing to work on health and wellness education. Therefore, the third influence that needs to be
assessed is the level of support from the fire chief and at least one wellness champion. Table 4
identifies three organizational influences that BOSH needs for success. These influences will be
used to more fully understand how HCFR may affect BOSH’s ability to develop and deliver
health and wellness education for its members.
Table 4

Organizational Influences and Assessments for Organization Gap Analysis
Assumed Organizational Influences Organizational Influence Assessment
BOSH needs to be given authority to prioritize
health and wellness across departmental programs.
What authority does BOSH have with
regards to initial or continuing health and
wellness education?
BOSH needs to be funded and staffed
appropriately for developing and implementing
health and wellness education.
How would you describe the resource
support, both human and financial, for
BOSH from HCFR?
BOSH needs to have the support of the fire chief
and one or more champions for generating buy-in.
How would you describe the Fire Chief's
commitment to health and wellness?
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Conceptual Framework: The Interaction of BOSH’s Knowledge and Motivation and the
Organizational Context
The purpose of a conceptual framework is to provide the reader with the lens that the
researcher has chosen to look at a problem (Maxwell, 2013; Merriam & Tisdell, 2016). This
allows the reader to better understand the researcher’s theory, which can come from the
literature, prior studies, and experience (Maxwell, 2013; Merriam & Tisdell, 2016).
Using the Knowledge, Motivation, and Organization (KMO) Gap Analysis framework
(Clark & Estes, 2008), the potential KMO influences have been presented independent of each
other. However, those influences constantly interact with each other. Indeed, knowledge and
intent are both needed for an individual (Nicomachean Ethics) or a group (Clark & Estes, 2008)
to be responsible for a task. However, the impact of the organization on the knowledge and
motivation of its members is critical to recognize (Clark & Estes, 2008; Schein, 2004).
As a bureau, BOSH is influenced by its overarching organization, HCFR, as well as the
knowledge and motivation of its members. Additionally, there is influence on fire departments
from national level organizations such as IAFF, NFFF, and NFPA, and state level organizations
such as MFRI. However, it is important to understand that there is constant multi-directional
influence that begins when the smallest level interacts with the next level up and so on. Indeed,
organizations at a macro level are influenced by the micro level, and the macro can then
influence the micro in a continual process of influence (Erez & Gati, 2004). The conceptual
framework presented here will outline the researcher’s theory of how the three KMO influences
interact with each other, as well as how the local, state, and national fire service interacts in the
overall context of the stakeholder goal.
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There are four main stakeholders involved in Figure 4. At the national level, there are fire
service organizations as depicted in the upper blue box. Below that is another blue box that
depicts the state level organization. On the right side of Figure 4, there are two circles. The large
(blue) circle depicts HCFR as the main organizational (and cultural) influence of BOSH, which
is depicted by the smaller (green) circle. However, both the national level fire service
organizations and the state level fire organization exert influence on HCFR.
The state agency, MFRI, provides the majority of courses available to career and
volunteer fire departments in Maryland, and thus has a sizeable influence on the education
available to firefighters. Furthermore, as stated by MFRI (2017), state training agencies also
strive to adapt to the needs of the fire departments they are serving. An arrow from the State Fire
Training Agency box to the blue HCFR circle depicts this interaction. In contrast, the national
level fire service organizations provide information and engage in promoting cultural change but
cannot directly influence local fire departments or state fire agencies. Two one-way arrows
depict this relationship of outside organizational (cultural) influence.
BOSH (small green circle) was created in 2014 to foster and maintain a work
environment that is built on safety, wellness, and health. One of the organizational goals of
BOSH is to eventually have 100% of firefighters receive health and wellness education
beginning in the academy and continuing annually throughout their careers. However, currently
there are no health and wellness courses offered from the state level (MFRI, 2017), or academy
curriculum models being offered at the national level. Therefore, one of BOSH’s stakeholder
goals is to develop such a physical and behavioral health and wellness curriculum which is
depicted by the yellow rectangle at the bottom of Figure 4. A dashed red line from the
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stakeholder goal to the state and national level represents the potential state or national model
developed by BOSH.
Within the green circle that represents BOSH, there are influences that must be present in
order to achieve the ultimate goal of providing health and wellness education to all of HCFR’s
firefighters. To effectively educate, individuals or organizations must have the requisite content
knowledge (Ball et al., 2008; Clark & Estes, 2008; Kirschner & Merrienboer, 2013), as well as
pedagogical knowledge (Alexander et al., 2009; Ball et al., 2008; Even, 1993; Grossman &
Salas, 2011; Krathwohl, 2002; Martin, 2010). Furthermore, individuals and organizations must
be motivated. They must find value in the effort they are being asked to make (Baicker, Cutler,
& Song, 2010; Clark & Estes, 2008; Eccles, 2009; Pintrich, 2003; Mayer 2011; Pronk, 2014), as
well as believe that their effort can create change (Aguinis & Kraiger, 2009; Anderman &
Anderman, 2009; Pajares, 2006), and then act on those beliefs.

Figure 4. Conceptual framework of fire service health and wellness influences.
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BOSH must have specific knowledge of the most critical health and wellness issues of
the fire service, the risk factors associated with them, and how to reduce those factors. Currently,
the number one cause of death on-duty is heart attack, but cancer and suicide deaths for
firefighters far outnumber on-duty heart attack deaths (NFPA, 2017). However, this knowledge
of the fire service is not generated by local fire departments. It is the national fire service
organizations, and researchers that are connected to those organizations, that research and
publish this information.
Currently, the fire service as a whole is presenting indications of poor health on average
(NFFF, 2016). Research has looked into firefighter culture and behavior and reveals that
firefighter’s wellness and fitness norms are not in line with recommended health behavior or
metrics (Baur et al., 2012; Dobson et al., 2013; Kay et al., 2001; Poston et al., 2011; Staley,
2008). The conceptual framework in Figure 4 is suggesting that the current fire department
culture is perpetuated due to a lack of departmental emphasis on health and wellness, which
stems from a lack of initial and continuing education.
Firefighters are trained to respond to emergencies. As Erez and Gati (2004) explain, the
micro influences the macro, and the macro in turn then influences the micro. The emphasis from
the national level fire service organizations has been on fitness or wellness programs to respond
to firefighters who seek help, as opposed to preventative initial education programs. The
IAFF/IAFC WFI has called for academy and continuing education, however they have not
offered a model for fire academy (initial) education. Initial education can break the cycle of the
fire service health and wellness cultural norms, and continuing education can help sustain
cultural change.
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The IAFF does recommend that fire departments obtain an individual capable of critically
reviewing research and transferring that knowledge to the department while also being familiar
with the fire service (IAFF, 2008). However, this is not so easy to do: without education, it is
difficult to develop an individual organically, and a non-fire service expert may not understand
the fire service. The only education available to firefighters are the initial certification courses to
become a peer fitness trainer or peer support team member and even those are not available to
every firefighter due to cost reasons. Therefore, continued and advanced education for a potential
wellness champion should extend beyond initial training as a fitness trainer or peer supporter.
The fire service culture thus feeds into the organization and affects the culture,
knowledge, and motivation of that local, state, or national organization. In Figure 4, HCFR is
influenced by the fire service culture of wellness and fitness norms. MFRI is a macro level
organization (state) in relation to a fire department (local) and thus is also influenced by the fire
service culture. That MFRI does not offer any health and wellness courses to firefighters, even
though its website states that it adapts to the needs of the fire service (MFRI, 2017), indicates
both a failure from local departments to demand those courses, and a failure of MFRI to
anticipate their need. These failures are an example of how organizational culture can affect
knowledge.
Knowledge, motivation, and organizational factors are all interconnected and are all
needed to assign full responsibility for success or failure. They have been that way since
Aristotle identified the four factors of individual responsibility. William Durant (1961)
paraphrased Aristotle’s thoughts on how an individual’s success or failure can be assessed by
writing “We are what we repeatedly do.” While one’s repeated actions do shape one’s
characteristics, one’s actions are not made in a vacuum. Actions are influenced by one’s culture
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 77

(Bandura, 1986). It would be appropriate then, whenever hearing of Durant’s famous
paraphrasing of Aristotle, to add a paraphrasing of Bandura: We do what we repeatedly see and
hear. For organizations to expect that individuals will repeatedly choose to live a healthy
lifestyle, they must provide education and a culture that supports it. The organization is only as
healthy as its individuals that comprise it, but the individuals are only as healthy as the
information and norms that the culture propagates. Figure 5 depicts the factors of both Aristotle
and Clark and Estes as they relate to assessing responsibility of the individual or the
organization. First the circumstances must be understood which involves identifying what can
and cannot be changed. Next, a measurement must be taken of the knowledge and motivation of
the individual or organization, as they relate to the goal, because both are necessary to correct a
deficiency or excess. Lastly, there must be an awareness of how the part is affected by the whole,
but also how the part contributes to the whole. Figure 5 also includes the charges of Aristotle and
Bandura as they relate to assessing individual or organizational success.

Figure 5. A theory-based individual and organizational assessment framework.
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Conclusion
The fire service is experiencing significantly higher rates of firefighter death from health
and wellness causes compared to death due to fires (NFPA, 2017). The three main health and
wellness issues of firefighters all have lifestyle factors associated with them as can be seen in
Figure 3. It may be true that occupational factors are involved in firefighter heart attack, suicide,
and cancer. However, the literature for both firefighter specific health and wellness, and general
health and wellness, reveal that most of these deaths are preventable through lifestyle
adjustments.
Knowledge, motivation, and organizational factors are critical to an organization’s
success or failure of their goals. Therefore, the purposes of this study are to understand the KMO
factors that may be preventing HCFR from educating its firefighters on physical and behavioral
health and wellness and understand what KMO factors are needed to successfully develop the
necessary health and wellness education. The literature review identified assumed KMO factors
that this study wishes to validate. The validation process will be described in the Methodology
section.
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Chapter Three: Methods
Physical and behavioral health and wellness issues are critical factors in firefighter death
in the United States. The literature suggested that the risk factors related to cardiac death and
suicide are preventable. Cancer, which is a growing threat to both the general population, and to
firefighters, is also shown to be preventable through environmental or lifestyle changes.
Therefore, the purpose of this research is to understand why initial and continuing health and
wellness education has not been implemented in Howard County Fire and Rescue. This research
aims to examine the key knowledge, motivational, and organizational factors or influences
(Clark & Estes, 2008) that facilitate or impede the Bureau of Occupational Safety and Health in
creating a physical and behavioral health and wellness curriculum for Howard County Fire and
Rescue.
This study is focused on the following research questions:
1. What are the BOSH staff members’ knowledge, motivation, and organizational needs
related to designing a comprehensive curriculum on physical and behavioral health and
wellness that is applicable to 100% of the members of the department?
2. What is the interaction between organizational culture and context and BOSH
members’ knowledge and motivation?
3. What are the recommended knowledge, motivation, and organizational solutions to
those needs?
Methodological Approach and Rationale
A multi-method approach with an emphasis on qualitative research was used for this
study. Surveys, document analysis, and interviews are all accepted tools used in mixed methods
studies (Creswell, 2014). These three methods provided for triangulation to limit potential bias in
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the conclusion (Maxwell, 2013; Merriam & Tisdell, 2016). A descriptive survey using a Likert-
type assessment was used to assess perceptions of BOSH. Additionally, an in-person interview
and document analysis were conducted. Interviews were conducted to help understand the
knowledge, motivation, and organizational factors that may have been preventing BOSH from
implementing a health and wellness curriculum and what KMO factors may have been needed to
do so. Organizational documents were analyzed to understand what policies were in place to
hinder or support BOSH in its goal of health and wellness education. Qualitative research
focuses on exploring meaning and explanation (McEwan & McEwan, 2003), and this research
was focused on why HCFR did not offer health and wellness education and what factors were
needed to do so.
Participating Stakeholders
The stakeholders in this study came from HCFR members who were affiliated with
BOSH. The stakeholders included those in the following categories: Fulltime assignment to
BOSH at HCFR headquarters; Peer Fitness Trainer (PFT) program; Peer Support Team (PST)
program, and; Field Safety Officers. There were 47 stakeholders affiliated with BOSH, all of
whom were invited to take a survey. However, not all the stakeholders were invited for
interviews. Creswell (2014) suggested that four or five interviews for case studies may be
sufficient. However, that number can be higher since the goal for qualitative inquiry is to
continue until saturation of new information is reached (Creswell, 2014; Merriam & Tisdell,
2016).
Qualitative studies purposefully seek out stakeholders who can help the researcher learn
the most (Merriam & Tisdell, 2016). Not all BOSH stakeholders had equal insight and influence
into past, current, and future health and wellness programs. Therefore, specific criteria were used
to reduce the number of stakeholders to recruit for interviews.
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 81

Interview Criteria and Rationale
Criterion 1. The first criterion was to target those holding an official position within
BOSH. This criterion operated as an automatic selection criterion. Using official position
prioritized stakeholders based on decision making authority and access to strategic information.
Qualitative research seeks to gain understanding from individuals that have the most insight and
influence into the problem being studied (Creswell, 2014).
Criterion 2. The second criterion considered which health and wellness certifications the
stakeholder had obtained. Stakeholders who were on both the PFT and PST teams were
prioritized over members that were on only one team. For members that were only on one team,
priority was given to members with advanced training or certifications.
Criterion 3. The third criterion was a combination of years of service with HCFR and
years of experience with BOSH. Ten years was used as a minimum service requirement in
HCFR. Among those stakeholders with 10 or more years, time working with BOSH was used to
select candidates. In the event of a tie regarding time with BOSH, the candidate with more time
in HCFR was prioritized.
Interview and Survey Sampling (Recruitment) Strategy and Rationale
The researcher in this study worked for HCFR in BOSH as the Health and Wellness
Coordinator. The researcher was the lowest non-probationary rank in the department which was
a firefighter/EMT. In this position, the researcher provided logistical support to the peer fitness
and peer support teams. When the researcher works where the study is being conducted, this
could compromise the research results (Creswell, 2014). If a researcher holds official rank over
those they are gathering data from, it can be one cause of receiving inaccurate data due to the
relationship dynamics at play (Creswell, 2014). In this study, however, the researcher held no
official rank. The rank of the researcher as firefighter meant that participants would not feel
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threatened if they decided not to share information. Furthermore, the chief of HCFR and the
chief of BOSH supported the anonymous feedback that this research would provide.
All stakeholders in BOSH were asked to complete a short survey. The survey was mostly
Likert-type items and assessed stakeholders’ beliefs about knowledge, motivation, and
organizational factors that related to the research questions. The survey data was used to identify
themes of belief that BOSH stakeholders had. Additionally, the survey provided a snapshot of
the perceptions of the entire stakeholder group to provide context for the interviews which
focused on in-depth inquiry into the key stakeholders’ understanding of the KMOs regarding
BOSH.
The stakeholder interview group was limited to the 15 individuals ranked as having the
highest insight and influence. Three of the individuals worked at headquarters in BOSH and
were automatically selected based on their positions alone. The other 12 individuals were
selected based on the stated criteria by using the internal directories of the BOSH stakeholder
groups.
All 15 individuals selected were emailed and contacted by phone and asked to participate
in an interview. If a stakeholder would have refused to participate, the 16th highest ranked
stakeholder would have been added to the list of potential interviewees. This process would
repeat until 15 stakeholders agreed to be interviewed. Interviews began with the three
automatically selected candidates going in rank order from highest to lowest. Stakeholders were
interviewed on HCFR property. Interviews continued into the remaining pool of candidates until
information saturation occurred. Information saturation happens when the researcher begins to
hear the same responses and no new insights are occurring (Merriam & Tisdell, 2016). Saturation
occurred before all 15 stakeholders on the interview list had been interviewed.
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Interviews were not the only sources of qualitative information. Document analysis is
another form of qualitative research and can include public documents or private documents that
the researcher may have access to (Creswell, 2014). Using more than one data source aids the
researcher in crosschecking the information that will be used to create categories and themes
(Creswell, 2014). The next section will consider the criteria used to select documents for review.
Document Analysis Sampling Criteria and Rationale
Criterion 1. The first criterion was subject matter. The document had to include
information that affected or can be affected by BOSH. Potential information included health and
wellness programs, health and wellness education, or organizational policy that affected BOSH.
Examples of organizational policy that may have affected BOSH included firefighter education
and training, promotional processes, and funding policy.
Criterion 2. The second criterion was the source of the document. The document must
have come from HCFR, MFRI, or a national fire service organization such as IAFF, NFFF, or
NFPA. Documents were prioritized based on the influence it had over BOSH and its programs.
Documents that were not produced by HCFR were reviewed to identify potential sources of
influence for organizational practices and policies.
Criterion 3. The last criterion was the date the document was published. Documents that
were over 10 years old were only considered if it could be shown that the document was relevant
to current practices or policy.
Document analysis Sampling (Access) Strategy and Rationale
The researcher in this study had frequent interactions with the members of BOSH. The
director of BOSH and the chief of HCFR had committed to support this research. The approval
of organizational or departmental gatekeepers is critical in gaining access to the information the
researcher is seeking (Creswell, 2014). Documents that are not already public information should
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be requested for the purposes of the research study via a written proposal with any ethical issues
addressed in writing (Creswell, 2014). No personal information was used in the research.
Explanation for Choices
Data collection for this research consisted of a survey, an interview, and document
analysis. The survey and interviews provided information on stakeholders’ beliefs,
understandings, and experiences of the KMO influences on BOSH. The document analysis
provided evidence that assisted in validating the surveys and interviews and identifying gaps in
policy that may have been affecting BOSH’s ability to achieve its goals. The literature suggests
using multiple forms of data for qualitative research (Creswell, 2014; Merriam & Tisdell, 2016).
Qualitative Data Collection and Instrumentation
Two methods of qualitative data collection were used in this research study. The two
methods were interviews and document analysis. Interviews were used to provide the researcher
with a rich understanding of the KMO needs, and potential solutions to these needs, regarding a
health and wellness curriculum for HCFR. Furthermore, the interviews sought to understand the
organizational factors that may have contributed to BOSH’s needs. Document analysis was used
to validate some of the data collected through the interviews, especially regarding organizational
factors involved. Both interviews and document analysis are commonly used in qualitative
research to triangulate data (Merriam & Tisdell, 2016).
Interviews
A one-hour recorded interview was conducted with 11 interviewees. Qualitative research
relies on the collection of rich data that reaches a level of saturation where no new data about the
research focus is being brought to light (Maxwell, 2013; Merriam & Tisdell, 2016). Therefore,
the number of interviews is flexible based on the data collected and 15 interviews were not
needed. The interviews were in person and conducted during, or immediately after, work hours
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and on HCFR property. HCFR properties included 12 different fire stations, the Public Safety
Training Center (PSTC), and HCFR headquarters. These worksite locations were government
facilities and had at least some security measures in place. Each location had at least one quiet
room that could be used to conduct an interview.
A semi-structured interview protocol was used in this research (Appendix D). There was
variance in the interviewee group regarding rank, experience, and specialized knowledge and so
the semi-structured protocol allowed for the flexibility to focus on the areas of insight that each
interviewee could best contribute towards. The flexibility also allowed the researcher to halt
further probing in areas that the interviewee demonstrated either discomfort or lack of
knowledge. The interview protocol included follow up questions that were used to probe further
if needed.
The interview protocol consisted of open-ended questions that were derived from
assumed KMO influences from both theoretical and content specific literature. Both peers from
the doctoral program and professors, who were experts in inquiry, reviewed and provided
feedback to the interview questions. The interview questions were designed to invite the
interviewee to share their understanding of any KMO deficiencies in BOSH generally, and any
ideas on how to improve. However, each answer was used to assess the stakeholder’s knowledge
and motivation. This design allowed for the most organic assessment of both BOSH as an
organization and the interviewees as key stakeholders.
Documents and Artifacts
Documents were collected for analysis during this research. Specifically, the researcher
collected published and unpublished documents from HCFR that related to the stakeholder goal
and the assumed influences outlined in the conceptual framework. As such, the researcher
collected and analyzed documents that related to BOSH’s health and wellness educational
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activity or responsibility, the current, or future, core curriculum of HCFR initial or continuing
education, and HCFR’s support for, or limitation of, BOSH’s efforts to conduct health and
wellness education by means of resources or policy.
The method of collection varied based on whether the targeted document was published.
In the case of a published document, collection was a matter of searching for and identifying the
targeted document and printing it and saving an electronic copy. In the case of a known
unpublished document or artifact, collection consisted of engaging the personal and professional
networks that the researcher had access to in order to attempt to obtain the document. In the case
of an unknown document being brought to light during interviews, or other data collection, the
researcher attempted to obtain the document by one of the manners listed above.
Data Analysis
This research incorporated qualitative and quantitative assessments of survey and
interview data using descriptive statistics. Survey data were analyzed for frequencies. Interview
data were generated after transcribing by using key words and coding into themes. The survey
data were collected from 46 individuals (out of 47 stakeholders) and interview data from 11
individuals. Documents were analyzed for knowledge and organizational influences which aided
in triangulation of survey and interview data.
Document analysis was conducted from September of 2016 to June of 2018. The surveys
were completed by stakeholders between June 2018 and July 2018. A checklist of stakeholders
was used to keep track of reported survey completions and the number of stakeholders reporting
was checked against the third-party online survey provider for accuracy. An overview of the
survey data was completed before interviews were conducted. Interviews were conducted from
July 2018 to August 2018. The interview protocol was designed to probe deeper into the
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perceptions and beliefs of the stakeholders from the survey protocol. The interviewees
represented an experienced and influential subset of the survey stakeholder group.
Data analysis was conducted between September 2018 and December 2018. Survey data
were analyzed by using the third-party online survey provider analysis, as well as using
Microsoft Excel. One individual skipped one item during the survey (Item 14) regarding the
commitment of the fire chief to health and wellness education. Interview data were transcribed
by an online service called Rev and was reviewed for accuracy. Interview data were then
analyzed according to the KMO influences using a qualitative research software called
ATLAS.ti, as well as Microsoft Excel. Triangulation of document analysis, survey data, and
interview data was conducted for each K, M, and O influence.
Credibility and Trustworthiness
Rich data collection, respondent validation, and triangulation are three ways that a
qualitative researcher can minimize threats to credibility (Maxwell, 2013). During the interviews,
the researcher requested to record the interview to produce a complete transcript. All but one
interviewee allowed the interview to be recorded. The interviewees were presented with a
summary of the researchers understanding of the data, to ensure that the researcher was clear on
the information the interviewee intended to provide. Once each interview data was confirmed to
accurately reflect the interviewee responses, the researcher saved that data for use in
triangulation of survey responses and document analysis.
The replicability of qualitative research is not easy due to human and societal changes
over time and differing interpretations of the same data (Merriam & Tisdell, 2016). Instead,
qualitative research should be judged on whether the results make sense based on the data
collected. To document what occurred and how the results came about, the researcher kept a log
of accounts throughout the collection process. Merriam and Tisdell (2016) refer to this as an
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audit trail. This log allows reviewers of the research to visualize the process of the qualitative
research and trust that the researcher did not just jump to a conclusion.
Quantitative Data Collection and Instrumentation
A survey was used in this research to aid in the triangulation of data. Surveys provide an
easy way to directly solicit many stakeholders’ opinions toward an issue (Fink, 2013). Although
direct questions could have been asked in an interview, the interview time was dedicated to
deeply understanding contextual issues, and the number of possible interviews for this research
was limited. The survey sought to provide ordinal data from the entire group of BOSH
stakeholders. Two items were included that asked stakeholders to assign a value from one to ten.
By focusing mainly on ordinal data, the survey provided a quick and simple way to have a more
robust understanding of how BOSH was perceived as it related to health and wellness education.
The survey data provided a sense of the opinions and perspectives of the entire BOSH
stakeholder group on the key needs outlined in the conceptual framework. This data from the
entire stakeholder group was analyzed in conjunction with the interview data of key
stakeholders.
Surveys
A 14-question mostly Likert-type descriptive survey was sent to all 47 stakeholders
within BOSH (Appendix E). This number included those that worked in BOSH headquarters as
well as those that worked in the field as safety officers, peer fitness trainers, or peer support team
members. The survey items were developed to capture perceptions from the stakeholder group
that aligned with the interview questions being asked of the key stakeholders. The survey items
were reviewed by peers and experts and were based on the research questions of this study and
theoretical and topic-specific literature. Fink (2013) stated that it can be difficult to ensure that
survey data being sought is the data that is collected, especially when seeking specific
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information. This issue can occur when the researcher is relying on the knowledge of the survey
taker. To avoid asking survey participants for information that they may not have known, the
survey questions focused on capturing stakeholder’s opinions on KMO factors that related to
BOSH. The factors were linked to the conceptual framework and the topic specific literature.
Validity and Reliability
By focusing strictly on opinion, a survey has increased validity because opinions cannot
be wrong (Fink, 2013). The survey for this research sought to gather opinions from BOSH
stakeholders about whether the assumed needs from the theoretical and topic specific research
were being met. Salkind (2017) suggests that to increase reliability, surveys should include
uniform instructions, clear survey items, and be taken with minimal distractions. Peer and expert
feedback were used to evaluate the survey instructions and items for clarity. The researcher
personally called each stakeholder to invite them to participate in the online survey. The
researcher was available to answer questions if necessary. The researcher held no rank authority
over the stakeholders and therefore should not have affected the way participants responded to
the survey.
The rate of survey response is a factor in the validity of the data (Fink, 2013). There are
many methods to increase response rates for surveys, and Fink suggests the use of incentives as
one method. However, no incentives were offered as the surveys were delivered while
firefighters were on duty and being compensated for that duty. Because this research was
sanctioned by HCFR, survey distribution to on-duty firefighters was supported. The intent of the
on-duty delivery of the survey was to maximize the survey response rate. While it was possible
and completely acceptable that some stakeholders may have refused to take the survey, it was the
expectation that most, if not all stakeholders, would participate.
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 90

Pazzaglia, Stafford, and Rodriguez (2016) explain that the use of laptops or other
electronic tools can aid in the survey process and in keeping data confidential. The delivery of
the surveys were done via an online third-party survey provider, in this case Google Documents,
which keeps the data secured and anonymous (Pazzaglia et al., 2016). Using an online survey
provider also served to minimize errors in organizing the survey data responses. A brief
explanation of what research was being done was included in an email sent to each of the 47
stakeholders.
Ethics
This study used a qualitative-leaning mixed methods approach to obtain data from
targeted human subjects with specific background in the research area. Because the number one
priority during research is to do no harm to the research participants (Maxwell, 2013), this
research was prepared in a way to maximize benefit to the fire service industry while minimizing
any psychological harm to participants. The benefit of this research was that it identified factors
that may be hindering initial or continuing health and wellness education in the fire service as
well as what was needed to address those factors. The risk to participants was limited to low-
level psychological stress during interview or survey data collection.
Research using human subjects must prioritize the protection of participants (Glesne,
2011). This study ensured participant protection by using an information sheet, confidentiality,
and the freedom to withdraw from the research at any time (Appendix J). The information sheet
notified the human subjects that they were participating in research to assess the KMO of BOSH
and BOSH stakeholders and that any data provided had the potential to be published research.
Confidentiality was maintained by a combination of securing raw data in a locked storage area,
and electronic data on a password protected laptop, with password protected files.
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 91

The survey and interview protocol both included questions that sought to understand
participants’ perceptions about the fire chief’s support of health and wellness. The fire chief
welcomed this data. The rationale for including a perception about a specific individual’s
performance was based on research by Kuehl et al. (2013) which indicated that the support of the
fire chief is critical for a successful wellness program to be implemented. As part of orienting
the participants to the survey and interview, the researcher stated that participants could skip any
question they did not feel comfortable answering.
The interview questions were designed to assess the key stakeholders by asking the
stakeholder to comment on the fire service culture, HCFR, and BOSH. This design allowed the
assessment process of stakeholders’ knowledge to advance organically and in a psychologically
safe way by signaling that the focus of data collection was about BOSH as a group. This study
has USC-IRB approval which signifies that a thorough review process had been conducted and
had determined that this study imposed no harm on the research participants.
The Office of the Fire Chief of HCFR and the director of BOSH both supported the
research being conducted and published without pseudonyms. The two oversight entities agreed
that it was possible to protect individuals who participated while still being transparent about the
organization being researched. The organizational command felt strongly that an organization
that intends to be a leader in their field should be willing to openly admit its shortcomings.
Furthermore, a simple internet search would reveal the organization of the researcher. Therefore,
a pseudonym was not used to hide the organizations name.
Lastly, it is acknowledged that in qualitative research, the researcher is the filter with
which all the collected information goes through (Maxwell, 2013). The researcher is a White
male and acknowledges that mental schema is not universal throughout all individuals but is a
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 92

factor of both nature and nurture. However, the researcher has extensive theoretical and practical
training and experience in non-biased information collection, documentation, and reporting for
both local and U.S. Government entities. Training and experience include time as a professional
EMT; a certified fitness trainer and certified health coach; a behavioral peer support team
member; a human-derived intelligence collector for the United States Coast Guard Reserve; and
an emergency management liaison officer for the United States Coast Guard Reserve.
Limitations and Delimitations
Limitations and delimitations are influences on a study. Limitations are influences
outside of the control of the researcher and delimitations are choices made by the researcher that
play a role on the study. There are limitations to this study based on its qualitative nature that
should be noted. This qualitative research study involved a researcher and research subjects, thus
allowing for multiple opportunities of human error to affect the research. Limitations include the
mental state of the stakeholders during their surveys while providing their opinions, and the
truthfulness of the stakeholders during the interviews. Limitations also include the knowledge
and experience the researcher has which were used to frame and conduct this study, as well as
the knowledge and experience the research participants have. Furthermore, this study was limited
by time, the number of research subjects in the study, and the region of the study which may
have influenced the culture of the researcher and the research participants.
The major delimitation factor is that the study was being conducted for HCFR, which is
just one organization. Delimitation choices by the researcher in this study included the criteria
used to select interviewees and documents for research, as well as the scope and number of
questions in the surveys and interviews. The survey, interview, and document analysis data that
was collected during this research represents a case study of HCFR and is not meant to be
generalizable to every fire department. However, the research can provide fire service
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 93

researchers with insight into potential factors to consider regarding initial and continuing health
and wellness education research. Furthermore, the KMO gap analysis framework (Clark & Estes,
2008) can be used by other researchers for investigating problems in their own departments.

HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 94

Chapter Four: Results and Findings
The purpose of this research was to conduct a needs’ analysis in the areas of knowledge,
motivation, and organizational resources necessary to innovate an initial and continuing physical
and behavioral health and wellness curriculum for firefighters. The Clark and Estes (2008) Gap
Analysis model was used as the framework to study the KMO needs of BOSH stakeholders
within HCFR. In addition to Clark and Estes’ Gap Analysis model, this chapter uses Ghaye’s
(2010) framework of purposefully positive reflective practice. Ghaye (2010) argues that
individuals, groups, and societies, may be better off assessing change through a positive lens to
determine what has gone right so far, and use that to build on the successes that exist. Therefore,
instead of using Clark and Estes’ traditional framework of validating gaps in the KMO, this
study framed the findings by identifying what the future needs were for KMO to continue
BOSH’s development.
A comprehensive literature review was conducted of physical and behavioral health and
wellness, theories on learning and motivation, and theories on organizational behavior and
change. Assumed KMO influences were identified during the literature review process. This
chapter presents the results of the survey, interviews, and document analysis that support
suggestions for knowledge, motivation, and organizational needs. The survey was sent to 47
stakeholders, one of which was unreachable due to long term leave associated with the Family
Medical Leave Act (FMLA). Out of the 46 stakeholders who were reached, 100% responded.
A table identifying whether a need existed is included for each section. The tables were
designed to present the triangulation of data that was collected during the survey, interview, and
document analysis portions of the research. For Likert-type survey data, a threshold of 66% was
chosen to indicate a large majority, and thus aid in determining whether a need for development
existed. For items that prompted respondents to provide a scale of value from 1-10, 66% or more
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 95

of combined responses in values 9 or 10 determined a large majority of highly positive value. A
table showing the mean and standard deviation to all 14 survey items can be found in Appendix
F. Interview responses were analyzed for key words and concepts to assess the interview group’s
response for each question. If 66% or more of interviewees provided a similar response, that
response constituted a large majority. If at least two of the three data collection methods
indicated a need, then “Development Indicated” was noted in the Future Needs column of the
table. Recommendations for needs are addressed in Chapter Five.
It should be noted that there was a time gap between the surveys and the interviews. The
surveys were completed during the months of June and July of 2018 and the interviews were
mostly completed by the end of August of 2018 (two were completed in mid-July of 2018).
HCFR experienced its first Line of Duty Death of a career firefighter on July 23, 2018. This
event became the priority of the department and thus had at least two consequences to the
research. The first is that the time between the survey data collection and interview data
collection increased, and thus the time for stakeholders to reflect on the survey questions
increased. The second is that the event had a significant behavioral health impact on the
department, and thus the importance of preventive behavioral education likely increased because
of the event.
The questions that provided a guide for this study are:
1. What are the BOSH staff members’ knowledge, motivation, and organizational needs
related to designing and delivering a comprehensive curriculum on physical and
behavioral health and wellness that is applicable to 100% of department members?
2. What is the interaction between organizational culture and context and BOSH
members’ knowledge and motivation?
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 96

3. What are the recommended knowledge, motivation, and organizational solutions to
those needs?
Results and Findings for Knowledge Influences
The entire BOSH stakeholder group, except for one individual who was using FMLA and
could not be reached, participated in the survey. Of the 46 individuals who participated in the
survey, 34 (73%) were male and 12 (26%) were female. Furthermore, 37 (80%) of the
respondents were White and nine (19%) were Non-White. The years of experience for the survey
respondents ranged from five or more years to over 30 years. Of the 11 individuals who
participated in the interviews, eight (72%) were male and three (27%) were female. There were
eight (72%) White interviewees and three (27%) Non-White interviewees. Lastly, of the
interviewees, two (18%) had 10 or more years of experience, six (54%) had 20 or more years of
experience, and three (27%) had 30 or more years of experience. Throughout the analysis of the
interview data for K, M, and O influences, interviewees will be identified using numbers 1-11
(i.e. Interviewee 1).
The knowledge needs were analyzed using data from surveys, interviews, and document
analysis. Two main knowledge influences were identified from the literature review on learning
theory. The influences were organized using Krathwohl’s (2002) framework for knowledge. The
first is the need to have the right content knowledge of the subject matter (declarative -
conceptual), and the second is to understand effective pedagogy (procedural). The assumed
knowledge needs for this study are shown in Table 5.
Table 5

Knowledge Needs
Assumed
Needs
Document
Analysis
Survey
Data
Interview
Data
Future
Needs
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 97

BOSH needs to have
the content knowledge
of physical and
behavioral health and
wellness issues that
affect firefighters.
Initial training
requirements
existed
Less than 66% of
stakeholders felt
they received
enough content
knowledge
K assets exist
but
stakeholders
desired more
Development
Indicated
BOSH needs to
understand effective
pedagogy.
No pedagogical
training
required
Less than 66%
felt they received
enough
pedagogical
knowledge
K assets exist
but
stakeholders
desired more
Development
Indicated

Results for the knowledge needs assessment were grouped into two sections that align
with the assumed influences in Table 5. By grouping the results this way, the assessment could
use the triangulated data of surveys, interviews, and document analysis in one section addressing
one influence at a time. The two sections are Knowledge of Physical and Behavioral Health and
Wellness Concepts, and Knowledge of Effective Pedagogical Processes.
Knowledge of Physical and Behavioral Health and Wellness Concepts
The findings indicated some knowledge assets but support the need for further
development of physical and behavioral health and wellness conceptual knowledge for BOSH
stakeholders. An initial training process existed for individuals to become a PFT or PST, and
survey and interview data revealed that BOSH had foundational knowledge assets within its
stakeholder group. However, development opportunities were identified in all three categories of
data analysis. The survey did not attempt to test the stakeholders’ knowledge of health and
wellness concepts. Instead, the survey prompted respondents to share their beliefs as to whether
BOSH had provided them the education they needed to development a health and wellness
curriculum. This section will review the findings from document analysis, survey data, and
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 98

interviews regarding BOSH stakeholders’ conceptual knowledge of physical and behavioral
health and wellness issues that affect firefighters.
Document analysis. Document analysis revealed that BOSH required initial
certifications for PFTs and PSTs. The required initial courses came from well-known entities
within the fitness and behavioral health industries. The PFTs in HCFR were required to complete
an initial self-study training program through the American Council on Exercise (ACE), and
afterwards pass an exam to become a certified personal trainer. The PFTs also had to recertify
every two years, which is done through completing continuing education. However, the
completion of the ACE exam does not signify physical health and wellness, or even fitness,
expertise, rather it is the minimum requirement to be a certified personal trainer. The PSTs in
HCFR were required to complete a three-day initial training program through the International
Critical Incident Stress Foundation (ICISF) as well as a four-hour training from the National
Fallen Firefighters Foundation (NFFF), called Stress First Aid. There was no requirement for
PSTs in HCFR to recertify. However, the completion of the ICISF course and the NFFF course
does not signify behavioral health and wellness expertise, rather it is the minimum BOSH
requirement to be a PST.
The PFT training from ACE focused on fitness instruction as well as some anatomy and
physiology, and the PST training from ICISF and NFFF focused on how to respond to a
coworker who is impacted by stress as well as some basic psychology. However, document
analysis also revealed that health and wellness concepts regarding heart attack, suicide or cancer
were not the focus of either the PFT or PST initial training. Furthermore, there was no state
sponsored education available for Maryland firefighters on heart attack, suicide, or cancer
prevention. Therefore, while HCFR PFTs and PSTs received initial training, they were not
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 99

required to complete training about heart attack, suicide, and cancer specifically, nor should
PFTs and PSTs be considered experts after initial training.

Figure 6. Respondent view of if BOSH provided them enough physical health and wellness
education to develop a comprehensive curriculum on firefighter physical health and wellness.
4%
50%
30%
9%
7%
BOSH has provided me enough education on physical health and wellness
to develop a comprehensive curriculum on firefighter physical health and
wellness.
Strongly Agree (2) Agree (23) Disagree (14) Strongly Disagree (4) N/A (3) Total (46)
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 100

Figure 7. Respondent view of if BOSH provided them enough behavioral health and wellness
education to develop a comprehensive curriculum on firefighter behavioral health and wellness.
Survey data. Survey data showed that less than the threshold of 66% of respondents
agreed that BOSH provided them enough physical or behavioral health and wellness education
for them to develop a curriculum on either category. Regarding physical health and wellness,
54% of respondents agreed and 39% of respondents disagreed, with 7% of respondents choosing
“N/A.” For behavioral health and wellness, the numbers were similar with 58% agreeing, and
37% disagreeing, and only 4% of respondents selecting “N/A.” Only two respondents (4%) out
of 46 strongly agreed about receiving enough physical or behavioral health and wellness
education. In contrast, four respondents (9%) strongly disagreed on physical health and wellness
and five respondents (11%) strongly disagreed on behavioral health and wellness. While over
half of stakeholders felt that they received enough education on physical health and wellness
(54%), and behavioral health and wellness (58%) to develop a comprehensive curriculum, the
threshold of a large majority (66%) of respondents that agreed was not met, demonstrating a
4%
54%
26%
11%
4%
BOSH has provided me enough education on behavioral health and
wellness to develop a comprehensive curriculum on firefighter behavioral
health and wellness.
Strongly Agree (2) Agree (25) Disagree (12) Strongly Disagree (5) N/A (2) Total (46)
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 101

potential area for development. Appendix F contains a table that shows the mean and standard
deviation for all 14 survey items. Table 6 shows the mean and standard deviation for the survey
items that address physical and behavioral health and wellness knowledge.
Table 6

Mean and Standard Deviation for Survey Items on Physical and Behavioral Conceptual Knowledge
Items
Strongly Agree (1) Agree (2) Disagree (3) Strongly Disagree (4)
Mean
Standard
Deviation
BOSH has provided me enough education on physical health and
wellness to develop a comprehensive curriculum on firefighter
physical health and wellness.
2.47 0.74
BOSH has provided me enough education on behavioral health and
wellness to develop a comprehensive curriculum on firefighter
behavioral health and wellness.
2.45 0.76

Figure 6 and Figure 7 provided an opportunity for respondents to indicate that the item
did not apply to them. However, it appears that for some reason, the respondents largely ignored
that option. Out of 46 respondents, 34 were Peer Support Team (PST) members that specialize in
behavioral health. That means that potentially 74% of respondents could have chosen the “N/A”
option for Figure 6, however only three respondents (7%) chose that option. Two respondents are
members of both the Peer Support Team (PST) and the Peer Fitness Trainer program (PFT) and
would not have likely responded “N/A” to either item. However, 12 PFT members (26% of
survey respondents) could have chosen the “N/A” option for Figure 7, but only two respondents
(4%) chose that option. Choosing not to select “N/A” could have been an oversight by most of
the survey respondents or perhaps it could have indicated an awareness of the survey respondents
that physical and behavioral health and wellness are both linked to heart attack, suicide, and
cancer as documented in the literature review. The interview data, which came from 11
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 102

interviewees, supports the idea that survey respondents as a group may have been aware of
crossover health associations.
Interview data. Table 7 presents mixed results on interviewee knowledge of the three
major health and wellness issues for firefighters, and the three major lifestyle factors that affect
those health and wellness issues as identified by the literature review. The interviewees
demonstrated high awareness of lifestyle factors of physical and behavioral health. Almost half
(45%) of all interviewees identified all three lifestyle factors and 100% of interviewees identified
at least two of the three lifestyle factors throughout the interview. Thus, over 66% of
interviewees identified over 66% of the lifestyle factors. All of the interviewees identified
nutrition as a lifestyle factor (the only factor that was identified by 100% of the interviewees),
and according to the literature review as shown in Figure 3, nutrition is connected heavily to both
physical and behavioral health. However, the interview data suggests a need for further
development of physical and behavioral health and wellness education for BOSH stakeholders
on behavioral health. Table 7 shows that none of the interviewees (0%) mentioned the word
suicide, nor did they imply the concept of suicide throughout the interview. Over half (54%) of
interviewees identified two of the three major health and wellness issues, and 100% identified at
least one. However, less than 66% of the interviewees identified over 66% of the health and
wellness issues.
Table 7

Percentage of Interviewees That Identified Physical and Behavioral Health and Wellness Issues
and Lifestyle Factors

Physical and
Behavioral
Health and
Number
of
Intervie
wees that
Percent
of
Intervie
wees that
Number
and
Percent
Number
and
Percent
Number
and
Percent
Did 66% or
more
interviewees
identify at
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 103

Wellness
Concepts
IDed
issue
IDed
issue
who IDed
all three
who IDed
only two
who IDed
only one
least 2 out
of 3 issues?
Heart Attack 8 73%
0
(0%)
6
(54%)
5
(45%)
No Suicide 0 0%
Cancer 9 82%
Physical Activity 10 91%
5
(45%)
6
(54%)
0
(0%)
Yes Nutrition 11 100%
Mental Activity 6 55%

These interview data demonstrate an awareness of the leading health and wellness issues
for firefighters and associated lifestyle factors. The data should not be taken to suggest that the
interviewees are ignorant about the issue of suicide in the fire service or mental activity as a
lifestyle factor. Conversely, identifying that heart attack and cancer are major health and
wellness issues for firefighters, and that physical activity and nutrition are important lifestyle
factors does not mean that the interviewees are comfortable educating on these concepts. Indeed,
all 11 interviewees took the survey and only two survey respondents strongly agreed that BOSH
provided enough education on either physical or behavioral health and wellness as seen in Figure
6 and Figure 7.
The interview data provided some additional insight that the survey data did not. While
there was a demonstration of awareness of health and wellness issues and lifestyle factors in the
interview data, albeit with some need for development, the interviewees expressed a desire for
further development on physical and behavioral concepts. Interviewee 1 stated, “I know mental
health, and nutrition, and physical fitness is good, but we don't have anybody out there following
through” on further education. Interviewee 8 shared a similar sentiment and said, “We can do a
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 104

whole lot better when it comes to fitness and nutrition education and also behavioral health
education.” These expressions might help explain why such a low number of respondents chose
“Strongly agree.”
Interviewee 10 felt that the culture of HCFR may be preventing a focused delivery into
any one educational topic. The person felt there is some level of introductory education about
health and wellness for the stakeholders: “We kinda give them a little bit just to get into trouble."
However, the individual went on to say “Then all of a sudden, it goes away…something else is a
hot topic. We never follow up with that information that we gave prior.” The interviewee seemed
frustrated that health and wellness education was not taken seriously.
Suggestions were offered on how to improve stakeholder health and wellness knowledge.
Exploring health and wellness research literature was suggested. Interviewee 9 stated, “I'm all
about education. I think there's a lot of literature out there we can do a lot of research around.”
Interviewee 3 suggested having “Quarterly trainings. If not, at least three trainings every year,
just updated science and updated research.” Additionally, obtaining feedback from individual
stakeholders could help. Interviewee 3 also believed that “A big part of it is also making sure
we're following up with our trainers of how they feel, what they feel to need to work on.” Taking
individual feedback even further, Interviewee 10 supported the idea of promoting specialization
within the PFT and PST teams. “It’s education…identifying those people and…what battle they
would like to fight and support that fight. Send them to different classes.” Interviewee 10 shared
their belief that it is difficult to get someone to learn something they are not interested in.
All three data analysis methods demonstrated that BOSH stakeholders do have a
foundation of health and wellness education. A foundation of health and wellness education is a
testament to the work that HCFR and BOSH have done to invest in the Peer Fitness Trainer
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 105

model and the Peer Support Team model. However, the data from document analysis, surveys,
and interviews all supported the conclusion that further development is needed for BOSH to
achieve its stakeholder goal of developing a comprehensive physical and behavioral health and
wellness curriculum.
Knowledge of Effective Pedagogical Processes
The findings supported the need for further development of pedagogical knowledge for
BOSH Stakeholders. Survey and interview data revealed that BOSH had some pedagogical
knowledge assets within its stakeholder group. In fact, the interviewee group demonstrated that a
large majority had at least an awareness of most of the pedagogical necessities outlined by the
literature review. However, needs were identified in all three categories of data analysis.
Document analysis. Document analysis revealed that BOSH did not require pedagogical
or instructional education prior to becoming a PFT or PST, nor did BOSH provide any initial or
continuing pedagogical or instructional education. However, the Maryland Fire and Rescue
Institute (MFRI) does offer free courses for firefighters on instructional processes. Fire Instructor
I, and Fire Instructor II are both available through MFRI. Furthermore, those who complete
Instructor II can begin a process to become a registered instructor for MFRI and receive
opportunities to teach classes for MFRI. Therefore, PFTs and PSTs can obtain no-cost state
sponsored pedagogical training and some have completed Instructor I, Instructor II, or higher
levels of pedagogical training.
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 106

Figure 8. Respondent view of if BOSH provided enough education on curriculum development to
develop a comprehensive curriculum.

Figure 9. Respondent view of if BOSH provided enough education on classroom instruction to
deliver a comprehensive curriculum.
4%
30%
44%
22%
BOSH has provided me enough education on curriculum development to
properly develop a comprehensive curriculum.
Strongly Agree (2) Agree (14) Disagree (20) Strongly Disagree (10) Total (46)
4%
24%
52%
20%
BOSH has provided me enough education on classroom instruction to
properly deliver a comprehensive firefighter health and wellness
curriculum.
Strongly Agree (2) Agree (11) Disagree (24) Strongly Disagree (9) Total (46)
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 107

Survey data. Survey data showed that less than the threshold of 66% of respondents
agreed that BOSH provided enough education on curriculum development or curriculum
delivery. Regarding curriculum development, only 34% of respondents agreed and 66% of
respondents disagreed. Figure 9 shows that for curriculum delivery, only 28% agreed, and 72%
disagreed. Furthermore, only two respondents out of 46 (4%) strongly agreed about receiving
enough curriculum development or delivery education from BOSH. In contrast, the number of
respondents that strongly disagreed were 22% and 20% respectively, roughly five times as many
as those who strongly agreed. While the survey data shows that some stakeholders felt they have
received enough education on curriculum development and delivery, the threshold of a large
majority (66%) of respondents who agreed was not met. In fact, a large majority of the
respondents (66% or more) disagreed with these two items demonstrating a need for further
development. Table 8 shows the mean and standard deviation for the survey items that address
curriculum development and delivery knowledge.
Table 8

Mean and Standard Deviation for Survey Items on Development and Delivery Procedural
Knowledge

Items
Strongly Agree (1) Agree (2) Disagree (3) Strongly Disagree (4)
Mean
Standard
Deviation
BOSH has provided me enough education on curriculum
development to properly develop a comprehensive curriculum.
2.83 0.82
BOSH has provided me enough education on classroom instruction
to properly deliver a comprehensive firefighter health and wellness
curriculum.
2.87 0.78

HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 108

Interview data. Table 8 presents data on interviewee knowledge of the three major areas
of the pedagogical process, and the three major factors for effective instruction as identified by
the literature review. The interviewees demonstrated high awareness of both areas. As a
reminder, the interviewees were screened for years in HCFR and years as a BOSH stakeholder.
Therefore, the interviewees represent some of the most experienced BOSH stakeholders.
Almost half (45%) of all interviewees identified all three main areas of the pedagogical
process and 100% of interviewees identified that passing information from the instructor to the
learner is part of the pedagogical process. Thus, over 66% of interviewees identified over 66% of
the main areas of pedagogy. Nine interviewees (81%) identified at least two of the three major
areas of pedagogy, 45% identified all three, and 18% identified only one. However, the interview
data suggests a need for further development of pedagogy in the area of assessment. Table 9
shows that assessment was only identified by 5 of the interviewees (45%).
Table 9

Percentage of Interviewees That Identified the Main Parts of Effective Pedagogy and Major
Traits of an Effective Instructor

Effective Pedagogy
(top 3) and
Effective Instructor
(bottom 3)
Number
of
Intervie
wees
Percent
of
Intervie
wees
Number
and
Percent
who IDed
all three
Number
and
Percent
who
IDed
only two
Number
and
Percent
who
IDed
only one
Did 66%
or more
interview
ees
identify
66% or
more of
the
issues?
Information 11 100%
5
(45%)
4
(36%)
2
(18%)
Yes Practice 9 82%
Assessment 5 45%
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 109

Content Knowledge 10 91%
6
(54%)
4
(36%)
1
(9%)
Yes Course Design 7 64%
Course Delivery 10 91%

These interview data demonstrate an awareness of the major areas of pedagogy. The low
number of interviewees that mentioned assessment should not be taken to suggest that the
interviewees are ignorant about assessment or pedagogy in general. Conversely, identifying that
passing information to a learner, and allowing the learner to practice the new information, does
not mean that the interviewees are comfortable educating learners. Indeed, all 11 interviewees
took the survey, and only two survey respondents strongly agreed that BOSH provided enough
education on either developing or delivering a comprehensive health and wellness curriculum.
Although the interviewees demonstrated the ability to identify the major areas of
pedagogy and instruction, one of the themes was a desire for further development as instructors.
Interviewee 3 stated, “The trainers [need] more opportunities for education.” Interviewee 8 said
that “Not all of our BOSH members are trained in teaching and if they're going to be teaching
they need to… to be taught how to relay the information.” Calls for more training from the
interviewees were in line with the survey results which suggested that BOSH stakeholders did
not have enough training on developing or delivering health and wellness education. Interviewee
2 wanted to “make sure [trainers] have some sort of background in taking instructor classes.”
The interview data suggests that more instructional development is warranted for BOSH
stakeholders.
A second theme was the expectation of the instructor to represent a higher standard.
Interviewee 1 felt that instructors “need to be at an expert level…in whatever subject they're
teaching.” Interviewee 10 stated that learners get more out of an instructor who is a “subject
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 110

matter expert [who is] educated and…passionate about what they're going to teach.” The
interviewees also mentioned instructional design. Interviewee 1 said, “students don't realize how
much it is behind the scenes, but it is a lot of work. It's a lot of prep.” According to Interviewee
9, good instructors need “to have the knowledge of those different levels of learning” to be
effective. The interviewees valued a highly knowledgeable and well-trained instructor, and
desired that for BOSH stakeholders.
A third theme was the need for more practice and feedback for the instructors.
Interviewee 7 felt that instructional practice is necessary because “Being a teacher is a skill. It's a
skill just like anything else.” Interviewee 10 shared about their development as an instructor and
stated that “If you allow them to teach and pass that information on, they're gonna…start being
the subject expert of those particular subjects.” However, part of developing through practice is
quality feedback. Interviewee 9 said, “Let them practice [teaching]. And, hopefully, with
somebody that is good at it.” Interviewee 7, who had a lot of experience put it this way,
“Practice. I mean, I think if you want to be a better swimmer, you swim. If you want to be a
better guitar player, you play the guitar.” Based on the interview data it appears that BOSH
stakeholders are not getting enough opportunity for instructional practice with feedback.
All three data analysis methods suggest that BOSH stakeholders have a need for
development in pedagogical knowledge. The interviews revealed that the most senior BOSH
stakeholders had a good understanding of the major areas of pedagogy and the key traits of an
effective instructor. However, the lack of required instructional training to become a BOSH
stakeholder, combined with the survey results and interviews suggest that instructor development
is a much-desired need. Therefore, the data from document analysis, surveys, and interviews
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 111

support the conclusion that further development is indicated for BOSH to achieve its stakeholder
goal of developing a comprehensive physical and behavioral health and wellness curriculum.
Synthesis of Knowledge Findings
BOSH stakeholders are all required to complete initial training from reputable industry
organizations. For PFTs, this includes how to safely instruct someone to complete exercises and
knowledge of the musculoskeletal structure of the body. For PSTs, this includes how to safely
respond to someone who is showing signs of stress and some basic psychology. However,
document analysis on the curricula of the initial training programs reveal that PFTs and PSTs are
not receiving conceptual knowledge about heart attack, suicide, or cancer, nor are they receiving
procedural knowledge on education design and delivery. Those topics are not the focus of the
initial training courses. Furthermore, the BOSH requirements to become a PFT or PST do not
include any education on heart attack, suicide, or cancer, nor do they include pedagogical
training. Therefore, while BOSH stakeholders receive specialized training in fitness and crisis
response, additional training may be needed to achieve the goal of developing a 16-hour
comprehensive physical and behavioral health and wellness curriculum for firefighters.
Additional education may require having conceptual knowledge specifically focused on heart
attack, suicide, and cancer, and procedural knowledge of designing and delivering education.
For both the content knowledge (conceptual) and the pedagogical knowledge
(procedural), the interview data aligned with the survey data; that more training and development
is needed to achieve the stakeholder goal. Conceptual knowledge and pedagogical knowledge
were targeted and analyzed, each being divided into two sections. The conceptual knowledge
portion was divided into a section on health and wellness issues that affect firefighters (heart
attack, suicide, and cancer), and another section on lifestyle factors that play a role in the health
and wellness issues (physical activity, nutrition, and mental activity). The pedagogical
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knowledge portion was divided into a section on effective pedagogy (information, practice, and
assessment), and another on what makes an effective instructor (content knowledge, course
design, and course delivery). Only the section on health and wellness issues had less than 66% of
interviewees identify less than 66% of target areas, thereby falling below the threshold. This
occurred because none of the interviewees (0%) identified, or alluded to, suicide as a major
health and wellness issue for firefighters. However, this does not mean that BOSH stakeholders
are ignorant about suicide in the fire service, but it may be an area of educational development.
For the data sets in Table 7 and Table 9 there appeared to be a correlation between one
item in each section for each table. There were four (out of 12) areas that were identified by less
than 66% of interviewees. For conceptual knowledge, it was suicide in the section on health and
wellness issues, and mental activity in the section on lifestyle factors. The low rate of identifying
suicide and mental activity could represent a specific need for stakeholder development. For
procedural knowledge, assessment and course design were mentioned less by interviewees.
Building in proper assessments to instructional programs requires proper instructional design
knowledge. This does not indicate that BOSH stakeholders are ignorant of these areas, it merely
identifies that those areas were not highly mentioned at the time. Identifying or failing to identify
areas during an interview cannot determine an interviewee’s knowledge. However, the themes
from the interviews appear to produce a message that correlates with the survey data. The
message is that more conceptual knowledge on physical and behavioral health and wellness, and
more pedagogical knowledge on course design and delivery are indicated.
Results and Findings for Motivation Influences
Motivation needs were analyzed using the data from surveys and interviews. Document
analysis was not used. Two main motivation influences were identified from the literature review
on motivation theory. The first was the need to see the utility value in educating firefighters
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 113

about health and wellness at the beginning, and throughout their careers. The second was the
need to understand that firefighter health and wellness can be changed through BOSH’s
educational efforts. The assumed knowledge needs for this study are shown in Table 10.
Table 10

Motivation Needs
Assumed
Needs
Survey
Data
Interview
Data
Future
Needs
BOSH needs to see the utility
value in educating firefighters
about health and wellness at the
beginning, and throughout their
careers for both the individual
and the organization.
Over 66% of
respondents find
value
Very strong
motivation assets
in stakeholder
value
Reinforce value
of health and
wellness
education
BOSH needs to understand that
firefighter health and wellness
can be changed through
BOSH’s educational efforts.
Over 66% believe
BOSH can affect
change
Strong motivation
assets in
attribution
Reinforce
attribution of
BOSH
educational
efforts

Results for the motivation needs assessment are grouped into two sections. The first
section reviews findings for stakeholder utility value and the second section reviews findings for
stakeholder attribution. The motivation assessment used data from surveys and interviews only.
The two sections are A High Degree of Value in Educating Firefighters on Health and Wellness
and Firefighter Health and Wellness Can be Changed through BOSH’s Efforts.
A High Degree of Value in Educating Firefighters on Health and Wellness
The findings indicated that there was not a need for development of stakeholder group
motivation. Both the surveys and interviews indicated substantial motivation assets within BOSH
and that its stakeholders found value in initial and continuing physical and behavioral health and
wellness education for firefighters. This section will review the findings from survey data and
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 114

interviews regarding BOSH stakeholders’ feelings, beliefs, and understandings about the utility
value of health and wellness education.

Figure 10. Respondent view of if educating firefighters on physical and behavioral health and
wellness in the academy should be a priority for HCFR.

76%
17%
7%
0%
Educating firefighters about physical and behavioral health and
wellness in the academy should be a priority for HCFR.
Strongly Agree (35) Agree (8) Disagree (3) Strongly Disagree (0) Total (46)
1
2
1
9
33
0
5
10
15
20
25
30
35
1
(0%)
2
(0%)
3
(0%)
4
(0%)
5
(2.2%)
6
(0%)
7
(4.3%)
8
(2.2%)
9
(19.6%)
10
(71.7%)
On a scale of 1 - 10 (10 being most important), how important do you
feel it is to educate firefighters about physical and behavioral health
and wellness in the academy?
Responses (46 Total)
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 115

Figure 11. Respondent view of how important physical and behavioral health and wellness is in
the academy.

Figure 12. Respondent view of if educating firefighters on physical and behavioral health and
wellness throughout their careers should be a priority for HCFR.

Figure 13. Respondent view of how important physical and behavioral health and wellness is in
throughout a firefighter’s career.
78%
22%
0%
0%
Educating firefighters about physical and behavioral health and
wellness throughout their careers should be a priority for HCFR.
Strongly Agree (36) Agree (10) Disagree (0) Strongly Disagree (0) Total (46)
1 1
8
3
33
0
5
10
15
20
25
30
35
1
(0%)
2
(0%)
3
(0%)
4
(0%)
5
(0%)
6
(2.2%)
7
(2.2%)
8
(17.4%)
9
(6.5%)
10
(71.7%)
On a scale of 1 – 10 (10 being most important), how important do you
feel it is to educate firefighters about physical and behavioral health
and wellness throughout their careers?
Responses (46 Total)
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 116

Survey data. A large majority of BOSH stakeholders found value in initial and
continuing health and wellness education. The survey prompted stakeholders to indicate whether
they agree or disagree with making health and wellness education a priority in the academy and
throughout firefighters’ careers. After the Likert-type question, stakeholders were prompted to
quantify the importance of initial and continuing education. This section provides a review of the
survey data starting with initial education, followed by continuing education. Table 11 shows
the mean and standard deviation for the survey items that address value of health and wellness
education.
Table 11

Mean and Standard Deviation for Survey Items on Value of Health and Wellness Education
Items
Strongly Agree (1) Agree (2) Disagree (3) Strongly Disagree (4)
Mean
Standard
Deviation
Educating firefighters about physical and behavioral health and
wellness in the academy should be a priority for HCFR.
1.30 0.59
On a scale of 1-10 (10 being most important), how important do you
feel it is to educate firefighters about physical and behavioral health
and wellness in the academy?
9.52 1.01
Educating firefighters about physical and behavioral health and
wellness throughout their careers should be a priority for HCFR.
1.22 0.42
On a scale of 1-10 (10 being most important), how important do you
feel it is to educate firefighters about physical and behavioral health
and wellness throughout their careers?
9.43 1.00

Figure 10 shows that 93% of stakeholders agreed that health and wellness education in
the academy should be a priority for HCFR. Of the 93% who agreed, 76% of stakeholders
strongly agreed. Of the 7% of stakeholders who disagreed, there were none who strongly
disagreed. The threshold of 66% was passed by those who strongly agreed alone. The responses
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 117

to the item in Figure 10 suggested a strong desire from stakeholders to see initial health and
wellness education.
The survey included an additional item that sought to quantify the importance of initial
health and wellness education. Combined, 90% of stakeholders indicated a very high importance
for initial education. Figure 11 shows that on a scale of 1-10, 10 being the most important, over
71% of stakeholders felt that initial education should be valued as a 10, and over 19% felt that
initial education should be valued as a 9. Five out of ten was the lowest value given which
represented roughly 2% (one respondent) of the stakeholder group. Roughly 4% (2 respondents)
indicated a value of 7 out of 10, and about 2% (1 respondent) indicated a value of 8 out of 10.
The mean for this item was 9.52, the median and mode were both 10, and the range was 5. The
responses to the item in Figure 11 suggest that stakeholders found high value in initial health and
wellness education.
Items involving continuing education on the survey followed the items on initial
education. Figure 12 shows that 100% of respondents agreed that health and wellness education
throughout a firefighters’ career should be a priority. The survey respondents who strongly
agreed amounted to 78%, which is higher than the threshold of 66%. Those who agreed made up
the remaining 22%. In contrast to initial education, Figure 12 suggests that BOSH stakeholders
put a higher priority on education during a firefighter’s career. Both the total number of those
who agreed, and the number of those who strongly agreed were higher for health and wellness
education throughout a firefighter’s career compared to initial education. This indicates a strong
desire from stakeholders to see continuing health and wellness education. However, the
following survey item which asked respondents to give numeric values for continuing education
provided a bit more to consider.
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 118

Figure 13 shows that BOSH stakeholders do find a high value in educating firefighters on
health and wellness throughout their career. On a scale of 1-10, 10 being the highest value, over
71% of stakeholders found that continuing health and wellness education should be valued as a
10. The same percentage of stakeholders valued initial education as a 10 out of 10 as well.
However, only 6% (3 out of 46) of stakeholders valued continuing education as a 9 out of 10. In
comparison, 19% (9 out of 46) of stakeholders valued initial health and wellness education as a 9
out of 10, which is a major difference. Just over 17% (8 out of 46) of stakeholders valued
continuing education as 8 out of 10. In contrast, only 2% (1 out of 46) of stakeholders valued
initial education as 8 out of 10. This suggests that a group of stakeholders might have valued
continuing education slightly less so than initial education. One respondent (2%) indicated a
value of 7 out of 10, and one respondent (2%) indicated a value of 6 out of 10. In contrast, the
lowest value for initial education was 5 out of 10. The mean for this item was 9.43, the median
and mode were 10, and the range was 4.
Interview data. The stakeholders that were interviewed shared passionate responses
about initial and continuing health and wellness education. One theme was that firefighters
should begin their careers with a clear and common message of health and wellness. A second
theme of continuing education centered on growth. Stakeholders expressed strongly that health
and wellness cannot just be a passing statement in the beginning of a firefighter’s career.
Interviewees also recognized that development opportunities exist for implementing health and
wellness education. It was clear during the interviews that a high value was placed on both initial
and continuing health and wellness education.
The fire academy for HCFR is a six-month program designed to bring a citizen with no
background in firefighting or emergency medical services and train them to become a firefighter.
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 119

Interviewee 2 stated that it is in the academy that firefighters learn the philosophies and
techniques of HCFR, “that way everyone has the same basic starting point, so you know what the
expectation is from the department.” Interviewee 3 succinctly said what others also expressed,
“We need to make sure that we're starting in the academy” when it comes to health and wellness.
The first theme was initial health and wellness education in the fire academy. Interviewee
1 felt that “everybody…needs to get [health and wellness education]”, and the academy is where
HCFR can ensure that everyone receives that education. Although firefighters go their separate
ways after the academy, Interviewee 3 stated that what firefighters learn during that time is
something “they’re gonna be able to take…with’em the rest of their career.” The academy is an
experience that firefighters always remember, “even for the people that have continued in their
career for 15-20 years.” Interviewee 5 stated that the information presented during the academy
“gives you the base line”, and Interviewee 3 believed “that first piece of information is what’s
gonna be the change.”
The interviewees also recognized the importance of cultural change in education.
Interviewee 3 felt that “If we’re starting when people are young into the department…they can
see we are about health, and…about taking care of each other.” However, there was a
recognition that development is still needed. One seasoned interviewee, Interviewee 6, was
passionate about the need to develop and said, “tell us what it is…tell us what the health and
wellness programs are.” The individual’s point was that there was not anything readily
identifiable as initial health and wellness education. The interviewees verbalized strong support
for initial education which is in line with the survey data.
The second theme was continuing education. Continuing education for HCFR firefighters
takes place throughout their careers. It might be informal education at the station level,
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 120

mandatory courses implemented from a department level, or formal education through state
sponsored courses or college. When it came to health and wellness education, Interviewee 5
summed up a common message that “we need to take more classes yearly.” Interviewee 4 felt
that “continuing [education] is going to help you process what's next and also help you improve
if you didn't feel you did the best you could the last time. Also, would help with muscle
memory.” Multiple interviewees recognized the value in learning new information as a group.
Again, Interviewee 5 stated clearly that “We can't go any further, we won't be able to grow,
progress as a department without [education].” When it is coordinated and mandatory,
“continuing education [helps] the department all together.” Interviewee 7 felt “We have to share
this knowledge and there's no doubt about it.”
Continuing education in HCFR includes dissemination of updated policy changes or
industry best practices. Health and wellness research evolves over time and in order for
firefighters to stay current, Interviewee 2 felt firefighters need to be aware of “any new updates,
any more information, any new study results.” Furthermore, Interviewee 4 felt that continuing
education can provide “more strategies on how to work through [a health and wellness issue].”
However, even if the information has not been updated, continuing education can be useful
because “if you didn't catch on the first time, maybe [you will on] the second, the third.”
Although the interviewees found high value in continuing education, when it came to
health and wellness, they recognized that there are still development needs. Interviewee 2 stated,
“As a department we haven't done a whole lot as far as continuing the health and wellness stuff.”
Interviewee 1 was a little more passionate, “What are we doing now for that? And that’s…not a
rhetorical question, but, what are we doing now? We’re not doing that much.” The lack of
continuing health and wellness education could be connected to a larger cultural shortcoming
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 121

within HCFR regarding continuing education. Interviewee 10 suggested said “We’re good at
throwing information out. I just don't think we're very good at following up on that information
and building upon those foundations.” The interviewees verbalized strong support for continuing
education which is in line with the survey data.
Survey and interview data both suggested BOSH stakeholders have very strong
motivational assets regarding the value of health and wellness education. As can be seen in
Figure 10 and Figure 12, a large majority (over 66%) of survey respondents strongly agreed that
health and wellness education should be a priority for firefighters in the academy and throughout
their careers. Furthermore, Figure 11 and Figure 13 show that a large majority of survey
respondents (over 66%) valued both initial and continuing education as 10 on a scale of 1- 10.
The interview data revealed that stakeholders see initial health and wellness education as a
necessary ingredient to long term cultural change, and that continuing education supports the
development of both the individual and the organization. Therefore, the data from the surveys
and interviews support the conclusion that development for stakeholder utility value of initial
and continuing education is not needed, but instead efforts should be made to reinforce the
motivation assets that exist.
Firefighter Health and Wellness Can be Changed through BOSH’s Efforts
The findings indicate substantial motivation assets in BOSH regarding the attributions
they make for BOSH’s efforts to change firefighter health and wellness. Both the surveys and
interviews indicated a strong belief that positive change for firefighter’s health and wellness is
attributable to BOSH’s future efforts. Because heart attack, suicide, and cancer have risk factors
that are highly preventable through lifestyle factors, the belief that BOSH is capable of affecting
positive health and wellness changes in firefighters is an asset. This section will review the
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findings from survey and interview data regarding BOSH stakeholders’ feelings, beliefs, and
understandings about the role BOSH plays in affecting change in firefighter health and wellness.

Figure 14. Respondent view on if education can change firefighters’ lifestyles and habits.

50%
48%
2%
0%
Education can change firefighters' lifestyles and habits.
Strongly Agree (23) Agree (22) Disagree (1) Strongly Disagree (0) Total (46)
43%
50%
7%
0%
BOSH is capable of improving HCFR firefighters' health and wellness
through education.
Strongly Agree (20) Agree (23) Disagree (3) Strongly Disagree (0) Total (46)
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 123

Figure 15. Respondent view on if BOSH is capable of improving HCFR firefighters’ health and
wellness through education.
Survey data. The BOSH stakeholder group agreed that education can change
firefighters’ lifestyles and habits as seen in Figure 14 and that BOSH is capable of affecting that
change as seen in Figure 15. Indeed, all but one individual (2% of respondents), chose either
strongly agree (50%), or agree (48%) to the item in Figure 14. The one individual who felt
different chose “disagree” and not “strongly disagree.” The percentage that agreed exceeded the
threshold of 66% and represented a large majority. However, compared to the items in Figure 10
and Figure 12 where over 75% of respondents strongly agreed that education was important, the
response to the item shown in Figure 14 shows that only 50% strongly agreed that education can
change firefighters. This might suggest that the survey respondents recognize that the importance
of offering education does not necessarily guarantee the positive effects of that education. Table
12 shows the mean and standard deviation for the survey items that address the attribution of
positive changes in firefighters to education in general, and HCFR firefighters by BOSH.
Table 12

Mean and Standard Deviation for Survey Items on Attributing Positive Firefighter Change to
Education and to BOSH
Items
Strongly Agree (1) Agree (2) Disagree (3) Strongly Disagree (4)
Mean
Standard
Deviation
Education can change firefighters’ lifestyles and habits. 1.52 0.55
BOSH is capable of improving HCFR firefighters’ health and
wellness through education. 1.63 0.61

The survey items transitioned from value of education to an abstract idea of attribution.
In Figure 14, survey respondents were prompted to attribute behavior change to education
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 124

generally. The next survey item went one step further and prompted respondents to attribute
behavior change to BOSH. In comparison with Figure 14, Figure 15 reveals a decrease in those
who chose “Strongly Agree” (from 50% to 43%), and an increase in those who chose “Disagree”
(from 2% to 7%). It appears that three individuals (roughly 7% of stakeholders), could not
“Strongly Agree” that BOSH can affect positive behavior change. Therefore, it appeared that as
items moved from the most abstract item regarding the value of education, to the least abstract
item regarding attribution to BOSH, the number of stakeholders who strongly agreed decreased.
However, altogether there were 93% of respondents that agreed that BOSH can affect positive
behavior change. This number is greater than the threshold of 66% and represents a large
majority.
The survey data from Figure 14 and Figure 15 revealed strong motivation assets with
regards to attributing behavior change to education, and to BOSH specifically. However, the data
also revealed a nuance in the groups’ understanding. The percentage of those who strongly
agreed about the importance of education decreased when asked about the effects of education
on behavior change, and then decreased further when asked about BOSH’s ability to affect
change. The nuanced changes revealed in the survey data are reinforced with interview data in
the next section.
Interview data. The interviewees demonstrated strong motivation for providing health
and wellness education to firefighters and indicated that BOSH should play the leading role in
that effort. Interviewee 4 felt that BOSH’s primary responsibility should “definitely [be]
education.” Interviewee 1 shared that education from BOSH should include “everything from
nutrition and mental health to physical health.” Furthermore, Interviewee 8 felt there should be
multiple methods of disseminating health and wellness information to include “providing
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 125

pamphlets, providing programs, and [other] resources.” Having a broad messaging program
provides an opportunity for individuals to overcome ignorance, because as Interviewee 5 stated
“[we] don't know what [we] don't know.” Interviewee 9 stated that additionally, the organization
benefits because “healthy employees do better long term. They have less injuries. Risk
reduction.” However, Interviewee 1 shared a concern that others had as well, which was whether
“BOSH [was] capable of [positively changing firefighter behavior].” They felt BOSH could be
doing more.
One theme was organizational responsibility to provide health and wellness education.
Interviewee 11 stated that as an organization, HCFR was not prioritizing firefighter health and
wellness the way they should. This interviewee expressed a desire that BOSH would receive
more political and financial support from HCFR for its mission and said “Firefighters are our
biggest asset. Why are we not taking care of our biggest asset?” Interviewee 1 expressed concern
about the lack of dedicated human resources at the program management level of BOSH. This
person recognized that BOSH had fitness trainers in the field but described the current state of
the fitness trainer program as “the sail's down, and the boat's just kinda floating out in the middle
of the river, or the ocean, or whatever.” Furthermore, because of the lack of program
management, Interviewee 1 and Interviewee 6 felt that “[BOSH doesn’t] do any teaching.” What
these data suggest, is that while interviewees believed that education can affect change, BOSH
needs to be more proactive.
Proactive engagement was another theme regarding how BOSH can affect positive
change in firefighters. Interviewee 1 suggested that BOSH should work “to utilize those fitness
trainers more.” Additionally, Interviewee 1 believed BOSH must actively engage others who
may need support and say “look, here's what we're gonna do, or here is an idea.” Interviewee 1
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 126

explained that proactive engagement is important because “the healthy people are the ones that
are gonna go looking for it, but people that aren't that healthy or aren't that engaged are the ones
that need it.” Interviewee 3 suggested BOSH be more focused on empowering PFTs and PSTs
both on and off duty to make them “available for any individual to meet any of their physical or
health and wellness needs.” However, Interviewee 1 felt that empowerment comes at a cost
because “people aren't gonna do stuff for free anymore.” Interviewee 8 felt that for BOSH to be
effective the PFTs and PSTs “need to have information, [they] need to have support, and [they]
need to have resources.” However, more resources are not always the answer, and the
interviewees understood this as well.
A third theme emerged during the interviews regarding individual responsibility. There
was no survey or interview item regarding individual responsibility. However, 10 out of 11 of
interviewees specifically commented on the need for an individual to help themselves. This
might explain the reduction in the percentage of survey respondents that chose “Strongly Agree”
as the items in the survey transitioned from the importance of education, to whether education
can positively change others, to whether BOSH can positively change firefighters. For the item
about whether BOSH can improve firefighters’ health and wellness with education, the survey
respondents may have been thinking about individual responsibility.
Some stakeholders described experiences with firefighters who knew what to do but
choose not to do it. For instance, Interviewee 1 stated that “everyone knows about high
cholesterol…high blood pressure…[eating] healthy…exercise; the problem is we don't do it.”
Interviewee 2 felt one reason could be that “some folks are always going to be 100 percent set in
their ways, and not going to change.” Another reason could be that individuals need coaching on
time and priority management. Interviewee 7 stated that “unless people take the time to put it in
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 127

their day…if it's not a priority, then it's not going to happen.” Interviewee 9 felt that coaching
may be the only way to improve outcomes for individuals because at the time of the interview,
HCFR “can't…force them to do it.”
The BOSH stakeholders as a group showed a balanced understanding of the dynamics of
organizational and individual responsibility. Interviewee 2 stated the organization should be
“giving the education, giving the [resources], what people do with it, you can't control.”
Interviewee 1 felt that the organization can also play a leadership role in supporting a “teacher-
student kind of compact, or their contract with each other. The teacher promises to teach, and the
student promises to learn.” However, Interviewee 5 noted that just “because we're educating
them doesn't necessarily mean that they want to change.” Individuals can either resist or engage
in “changing their mindset.” The organization is responsible for providing the education and
resources, but “[people] themselves [have] to believe that's where [they] want to be and they
have to step up themselves to figure out that they want to live a healthy lifestyle.”
Both the survey and interview data suggest that BOSH stakeholders had strong
motivational assets regarding attribution of change to education in general and to BOSH
specifically. A large majority (over 66%) of survey respondents agreed that education can
change firefighters’ lifestyles and habits. Additionally, a large majority of survey respondents
(over 66%) agreed that BOSH is capable of improving HCFR firefighters’ health and wellness
through education. The interview data revealed that stakeholders see BOSH as the primary
organizational component for providing physical and behavioral health and wellness education to
firefighters. However, the stakeholders also recognized that there is a balance between
organizational responsibility and individual responsibility. Indeed, even with all the resources
and support available, some individuals may resist changes to their own detriment. The
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 128

interviewees wanted to see better support for BOSH to proactively engage with, and educate, the
firefighters in HCFR. The survey and interview data support the conclusion that development for
stakeholder motivation is not needed. Instead efforts should be made to reinforce the motivation
assets about organizational responsibility and the impact that BOSH can have on individuals
willing to engage.
Synthesis of Motivation Findings
The survey and interview data indicate that BOSH had strong motivation assets in its
stakeholder group. Survey data revealed a very high utility value of initial and continuing health
and wellness education. A large majority (over 66%) of the BOSH stakeholders strongly agreed
that both initial and continuing education should be a high priority. Furthermore, the BOSH
stakeholders indicated a high numeric value in both initial education (mean of 9.52 on a 1- 10
scale) as well as continuing education (mean of 9.43 on a 1- 10 scale). The survey data also
revealed strong assets regarding attribution. A large majority (over 66%) agreed that education
can change firefighters’ lifestyles and habits, and that BOSH is capable of positively affecting
HCFR members through health and wellness education.
There was a notable difference in the survey responses on items of utility value and of
attribution. The percentage of respondents that strongly agreed with the items on the value of
health and wellness education was over 66% for both initial and continuing education. However,
for the items on attributing behavior change to education in general, and to BOSH in particular,
the percentage of respondents that strongly agreed was much less; neither item had over 50% of
respondents that chose “Strongly Agree.” The interview data on individual responsibility may
have addressed the decrease.
Ten of the eleven interviewees talked about the dynamic of individual responsibility and
organizational responsibility. They shared personal experiences and an understanding of human
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 129

behavior that people cannot be forced to engage in something that they do not want to engage in.
However, the organization must fulfill its responsibility and the interviewees expressed strong
motivation for health and wellness education. The stakeholders saw the fire academy as a major
component in organizational change and believed that health and wellness education should
begin there. Furthermore, a continued message of health and wellness, with updated information,
is critical for the organization to grow together. The BOSH stakeholders showed strong assets in
motivation. The reinforcement of those assets regarding the value of education, and the ability
for BOSH to affect change with willing individuals should be nurtured.
Results and Findings for Organizational Influences
The organizational needs were analyzed using data from surveys, interviews, and
document analysis. Three main organizational influences were identified from the literature
review on organization theory and applied to BOSH. The first is the need for BOSH to be given
authority to prioritize health and wellness across departmental programs. The second is the need
for BOSH to be funded and staffed appropriately. The third is the need for BOSH to have the
support of the fire chief and one or more champions. The assumed organizational needs are
shown in Table 13.
Table 13

Organizational Needs
Assumed
Need
Document
Analysis
Survey
Data
Interview
Data
Future
Needs
BOSH needs to be
given authority to
prioritize health and
wellness across
departmental
programs.
BOSH has
no authority
to mandate
education
Over 66%
believe more
authority is
needed
Stakeholders
believe more
authority is needed
Development
Indicated
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 130

BOSH needs to be
funded and staffed
appropriately for
developing and
implementing
health and wellness
education.
BOSH has a
budget
Over 66%
believe BOSH
does not have
enough resources
Stakeholders
believe more
funding and
staffing is needed
Development
Indicated
BOSH needs to
have the support of
the fire chief and
one or more
champions for
generating buy-in.
BOSH
exists and is
funded
Less than 66%
believe fire chief
is committed
Stakeholders feel
more fire chief
support is needed
Development
Indicated

Results for the organizational needs assessment are grouped into three sections that align
with the assumed influences in Table 13. By grouping the results this way, the assessment can
use the triangulated data of surveys, interviews, and document analysis in one section addressing
one influence at a time. The three sections are Organizational Authority to Prioritize Health and
Wellness, Appropriate Funding and Staffing, and Support of the Fire Chief and Wellness
Champion.
Organizational Authority to Prioritize Health and Wellness
The findings supported the need for further development of BOSH authority. Document
analysis revealed that BOSH did not have health and wellness educational curricula in place, but
that there was some history of approved department-wide fitness initiatives. Survey and
interview data suggested that BOSH should be more empowered to mandate education on health
and wellness. This section will review the findings from document analysis, surveys, and
interview data regarding BOSH’s authority to prioritize health and wellness within HCFR.
Document analysis. Document analysis revealed that BOSH’s Strategic Plan included
goals of health and wellness education. However, no initial or continuing health and wellness
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 131

educational curricula was found. Document analysis included recruit training curricula during the
academy and during the probationary year after the academy, promotional requirements, officer
candidate school, and quarterly officer training. According to the discoverable policies in HCFR,
BOSH did not have the authority to implement initial or continuing health and wellness
education on its own. The authority to implement new education would have to come from the
deputy chief level, which is one level above the director of BOSH and one level below the fire
chief. However, document analysis did reveal that some BOSH training initiatives had been
approved in the past, including physical fitness assessments and safety education for field
members. Therefore, although BOSH lacked the standing authority to implement initiatives on
its own, the opportunity likely existed for BOSH to submit educational programs for approval.
This history suggests that there is room for BOSH to grow its initiatives.

Figure 16. Respondent view on if BOSH should have the authority to mandate physical and
behavioral health and wellness education.
39%
35%
22%
4%
BOSH should have the authority to mandate physical and behavioral
health and wellness education throughout all stages of a firefighter's
career.
Strongly Agree (18) Agree (16) Disagree (10) Strongly Disagree (2) Total (46)
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 132

Survey results. The BOSH stakeholder group agreed that BOSH should have the
authority to mandate physical and behavioral education throughout all stages of a firefighter’s
career. A total of 74% of respondents agreed and 39% strongly agreed. In contrast, just over a
quarter of respondents (26%) disagreed that BOSH should have the authority to mandate health
and wellness education. Out of the 46 respondents, two (4%) strongly disagreed. The percentage
of those who agreed constituted a large majority surpassing the threshold of 66%. Furthermore,
those who chose “Strongly Agree” made up the largest group of respondents to this item. Table
14 shows the mean and standard deviation for the survey item that addresses BOSH authority to
mandate physical and behavioral health and wellness education.
Table 14

Mean and Standard Deviation for Survey Items on BOSH Authority
Items
Strongly Agree (1) Agree (2) Disagree (3) Strongly Disagree (4)
Mean
Standard
Deviation
BOSH should have the authority to mandate physical and behavioral
health and wellness education throughout all stages of a firefighter’s
career.
1.91 0.89

The survey data from Figure 16 revealed a desire for development with regards to
BOSH’s authority. However, the data also revealed that those who strongly agreed only slightly
outnumbered those who agreed. The split could have represented a lack of clarity within the
stakeholder group as to what BOSH’s authority was regarding program implementation.
Alternatively, the split could have been the result of the way the item was worded. Mandate is a
strong word, and “all stages of a firefighter’s career” is broad. The wording might also explain
why 26% of respondents disagreed. The interview data in the following section looked further
into the stakeholder’s thoughts and understandings of BOSH’s authority.
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 133

Interview data. The interviewees demonstrated a strong desire for BOSH to have
increased authority to mandate education. Interviewee 1 felt that BOSH was “a dog without a lot
of bite, authority wise.” Out of 11 interviewees, eight (72%) expressed a belief that health and
wellness education should be mandatory or enforced. Interviewee 11 expressed frustration that
BOSH doesn’t have enough authority and stated “if we aren’t taking care of our people then
shame on us. We already have all the good equipment we need like trucks, engines. BOSH needs
more respect.” Many of the interviewees expressed that they would like to see “something
enforceable”, as Interviewee 1 put it. Interviewee 11 argued for mandatory health and wellness
education because “[apparatus] driver, [emergency medical technician] have mandatory recerts”
so health and wellness should be treated the same. Interviewee 3 shared that “we have to
do…confined [space] recert” as an example of mandatory training. The overall theme was
expressed by Interviewee 8 that eventually “every person in the department gets [health and
wellness] training…just like our EMT re-certification. It's required.”
Another theme was that interviewees were not sure about what BOSH currently had
authority to do. Interviewee 3 thought that “there's a pretty good amount of authority, not as
much as we could have.” However, Interviewee 5 felt that when it comes to authority, BOSH
had “none; only for the fitness trainers…but as far as a regular firefighter, none.” Interviewee 6
stated “I'm not in that position to know why, what the authority, if their authority is. If they've
got intentions to do certain things and they're not being allowed to, I don't know.” Interviewee 7
was unsure and stated “as far as authority goes, I'm not sure. I don't know if even [The Director
of BOSH] could be like, ‘This needs to be in the academy’.” The lack of clarity regarding
BOSH’s authority suggests that better messaging to stakeholders may be a possible area of
development.
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 134

A third theme was about the nature of authority and that perhaps BOSH’s place in the
organizational hierarchy is currently inadequate. Interviewee 8 shared that when it came to
program design, BOSH could create any program it wanted, but “when it comes to approval of
whether or not the program will be delivered…we have to get permission…beg, borrow, or steal
to make it happen.” Some interviewees wondered whether BOSH’s status at its current level
made it inappropriate for it to have authority over other bureaus. Interviewee 9 stated that “When
you speak of authority, it comes the fire chief down…to the different bureaus. There's nothing
out there that says they have to cooperate on initiatives. And, I think that should change.”
However, what BOSH has been charged to do affects every member of the department, including
the fire chief. Interviewee 4 said “I would put BOSH right up to the front…to be treated at a
minimum equally [with the other bureaus]. However, I think BOSH has a higher priority because
it's all about mental and physical health.” The last quote provided a sentiment that BOSH was
not being treated equally as a bureau, but also includes the complexity of authority issues that
concern BOSH since its mandate is about the health and wellness of all employees of HCFR.
All three data analysis methods demonstrated that BOSH has development opportunity
regarding its authority to mandate physical and behavioral health and wellness education. The
survey and interview data revealed strong support for BOSH to have the authority to implement
mandatory health and wellness education. However, both document analysis and interview data
revealed that some previous BOSH initiatives had been approved. Therefore, the perception that
BOSH needs more authority may stem from a lack of developing and proposing programs. The
next section reviews resource allocation for BOSH, which affects its ability to develop programs.
Appropriate Funding and Staffing
The findings supported the need for further development of BOSH resources. Document
analysis revealed that BOSH did have a budget. Survey and interview data suggested that BOSH
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 135

should have more funding and personnel. This section will review the findings from document
analysis, surveys, and interview data regarding BOSH’s financial and human resources.
Document analysis. Document analysis revealed that BOSH did have a budget and full-
time personnel. Review of budgetary documents included a publicly released county government
budget as well as internal division budgets for purchasing and overtime expenses. Since BOSH
was created in 2014, it had received an initial budget each fiscal year. However, for every year
that BOSH had existed, its budget was cut and used for other programs within HCFR.
BOSH began with three uniformed employees in 2014. The number of personnel
increased to four uniformed employees and two civilian employees in 2016. The positions
included a director of BOSH, a program manager of safety, a program manager of occupational
medicine, a program manager of risk management, an administrative assistant, and a pilot
position for a program manager of behavioral health. According to the Strategic Plan and
position descriptions, none of the positions that were filled in BOSH were tasked with
developing preventive health and wellness education. As of the end of 2018, BOSH remained at
four uniformed employees and two civilian employees. According to BOSH’s Strategic Plan, one
program manager position and two assistant director positions have not been filled.
The document analysis process revealed that in 2014, BOSH was created, staffed, and
funded, and that some funding and staffing growth has occurred. However, according to BOSH’s
strategic plan, its personnel was still below its requested level, and its funding had historically
been cut each year of its existence to support other programs within HCFR. The following
section will review survey and interview data regarding stakeholders’ views on BOSH’s resource
allocation.
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 136

Figure 17. Respondent view on if BOSH receives enough resources to educate firefighters on
health and wellness throughout all stages of their career.
Survey data. The BOSH stakeholder group disagreed that BOSH received enough
resources to educate firefighters on health and wellness throughout all stages of their career. A
total of 72% of respondents disagreed and 18% strongly disagreed. In contrast, roughly a quarter
of respondents (26%) agreed that BOSH receives enough resources. Out of the 46 respondents,
one respondent (2%) strongly agreed. The percentage of those who disagreed constituted a large
majority surpassing the threshold of 66%. Table 15 shows the mean and standard deviation for
the survey item that addresses BOSH resources for health and wellness education.
Table 15

Mean and Standard Deviation for Survey Item on BOSH Resources
Items
Strongly Agree (1) Agree (2) Disagree (3) Strongly Disagree (4)
Mean
Standard
Deviation
2%
26%
54%
18%
BOSH receives enough resources to educate firefighters on health and
wellness throughout all stages of their career.
Strongly Agree (1) Agree (12) Disagree (25) Strongly Disagree (8) Total (46)
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 137

BOSH receives enough resources to educate firefighters on health
and wellness throughout all stages of their career.
2.87 0.72

The survey data from Figure 17 revealed a desire for development with regards to
BOSH’s resources. However, the number of those who strongly disagreed made up only about
one third of those that disagreed. The relatively small number of those who strongly disagreed
along with the number of stakeholders who agreed might suggest that BOSH’s situation with
regards to resources was not in dire straits. The interview data in the following section looked
further into the stakeholder’s thoughts and understandings of BOSH’s funding, staffing, and
situation relative to HCFR’s surrounding jurisdictions.
Interview data. The interviewees demonstrated a desire for BOSH to have increased
financial and human resources. From a financial resource standpoint, the health and wellness
program of BOSH is responsible for fitness equipment, initial and continuing training of PFTs
and PSTs, and educational initiatives for the department. However, all of these responsibilities
require funding and according to Interviewee 8, “[BOSH] has never been funded fully.”
One of the themes was that BOSH has never been fully funded because it is not a priority
of HCFR. Interviewee 9 felt that funding comes “if it's available”, and Interviewee 4 felt that
BOSH gets “what's left over.” Interviewee 10 felt that “[BOSH] should have definitely a bigger
role within the department.” Interviewee 4 felt that BOSH should be funded like Special
Operations who get to “travel [and] get administrative leave. The standard's not even close for
BOSH.” The interviewees shared a belief that resources are a representation of prioritization.
Another theme was how the lack of resources affected the ability for PFTs and PSTs to
stay proficient. Interviewee 1 stated that “We can't even get paid to go to training. You know, we
can barely get paid to get CEU's done.” Interviewee 2 stated that “continuing health education
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 138

wise, I don't think we've done a whole lot. I think it needs to be improved.” Training PFTs and
PSTs could be affected by prioritization. Interviewee 6 stated that “Whatever the hottest issue is,
is going to get all the resources.” Interviewee 4 found ways to make it to training but “It’s been
on my own time. It's been partial trips, splitting meals.” Interviewee 4 stated that PFTs and PSTs
are told to “use your own leave. [Attend training] on your own time. But we'll reimburse you for
your fuel.” BOSH members want to help but when it is so often with their own money “it's a
hard one to swallow.” Interviewee 1 concluded that “I don't think that there's enough money in
BOSH to [educate effectively].”
A third theme was the staffing level of BOSH. Interviewee 7 stated that BOSH “could
certainly use a couple more people” at headquarters. However, not all stakeholders of BOSH
knew exactly what happens at headquarters. Interviewee 2 stated that “I'm not there day in, day
out, so I'm not sure what your needs are [for] running your programs…from what I see everyone
seems to be running pretty efficiently.” Interviewee 6 stated that “sufficient personnel for any
bureau is always an issue. It's always tough. I think…for now…it's probably sufficient enough.”
One interviewee stated that although “more people would be helpful. We're fortunate that we
have the personnel we have in those positions.” While most of the stakeholders agreed that more
personnel would be helpful in developing and implementing health and wellness education, they
also recognized how much BOSH already had.
The recognition of how well HCFR and BOSH were doing was the final theme regarding
resources. Nine out of eleven (81%) of interviewees identified, without prompting, that HCFR
was doing well compared to other jurisdictions from a resource standpoint. Interviewee 6 shared
that “other departments close to us...some probably don't even have a BOSH Bureau. We're very
fortunate as far as that goes.” Interviewee 6 felt that “we're leaps and bounds in all these areas,
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 139

health, wellness and safety compared to other departments around us.” However, even as
interviewees recognized where HCFR stood in comparison to other jurisdictions, some, like
Interviewee 1, felt that “we can't look at it that way…we have to look at ourselves and evaluate
ourselves, not compare ourselves to another county.” Interviewee 8 mentioned specifically that
“we can do a whole lot better when it comes to fitness…nutrition…and behavioral health
education. We are not quite there yet. Better than some, but not good enough.” It was not lost on
the interviewees that HCFR was doing well in comparison to other jurisdictions with regards to
resources.
Recommendations from interviewees about how to increase funding and staffing were
provided. Interviewee 2 felt that better organization and submitting more proposals would help
because “the resources are there, it's just a matter of…taking advantage of it.” However, most of
the interviewees felt that better data tracking and documentation of current efforts would help.
Interviewee 3 stated that tracking could “justify the money that is needed for some of the
programs that we would like to see grow.” The interviewees felt that because BOSH must
compete for resources, data tracking is a fundamental necessity to program justification and
growth.
Support of the Fire Chief and Wellness Champion
Document analysis, survey data, and interview data suggested that further development
of fire chief support was needed for health and wellness education. No documents were
identified as useful for analyzing the presence of a wellness champion and their commitment to
health and wellness education. Instead, wellness champion data came from the survey and
interviews only. The survey data indicated that BOSH had at least one person who stakeholders
identified as a wellness champion. The interview data suggested that there was strong
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 140

commitment within the stakeholder group. This section will review the findings from document
analysis, surveys, and interview data regarding support of the fire chief and wellness champion.
Document analysis. Document analysis revealed that BOSH had some assets regarding
support from the fire chief. A BOSH budget was shown to have existed, and since BOSH was
created in 2014, the budget grew modestly. The BOSH budget included annual medical
screenings, gym equipment, and some money for training safety officers, peer fitness trainers,
and peer support team members. Additionally, according to the official document that outlines
promotional requirements, safety officer training is necessary to be promoted from firefighter to
lieutenant. However, in comparison to other bureaus, BOSH funding was significantly less.
Furthermore, a promotional preference was given to Special Operations members, paramedics,
and state certified training instructors, but not to PFTs or PSTs. Lastly, no health and wellness
curricula existed in the fire academy, or for Officer Candidate School (OCS). Therefore,
document analysis revealed that BOSH was supported, but less so than other bureaus, and with
little or no documented support for health and wellness education.
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 141

Figure 18. Respondent view on if the fire chief is fully committed to health and wellness
education.

Figure 19. Respondent view on if BOSH has at least one member that is fully committed to health
and wellness education.
16%
44%
36%
4%
The Fire Chief is fully committed to health and wellness education.
Strongly Agree (7) Agree (20) Disagree (16) Strongly Disagree (2) Total (45)
76%
20%
2%
2%
BOSH has at least one member that is fully committed to health and
wellness education.
Strongly Agree (35) Agree (9) Disagree (1) Strongly Disagree (1) Total (46)
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 142

Survey data. The majority of the BOSH stakeholder group agreed that the fire chief and
at least one BOSH member was fully committed to health and wellness education. However,
Figure 18 shows that regarding the fire chief, only 60% of stakeholders agreed with 16% of
stakeholders who strongly agreed. There was a total of 40% who disagreed, but only 4% (2
respondents) strongly disagreed. One stakeholder withheld from answering this survey item and
so the total responses were 45. Therefore, while there were more stakeholders in agreement that
the fire chief was fully committed to health and wellness education, the data suggests that the
stakeholders did not feel strongly one way or the other. The threshold for a large majority (66%)
of agreement was not met regarding the fire chief’s commitment. Table 16 shows the mean and
standard deviation for the survey items that address the perceived commitment of the fire chief
and at least one member in support of health and wellness education.
Table 16

Mean and Standard Deviation for Survey Item on Fire Chief and Member Commitment
Items
Strongly Agree (1) Agree (2) Disagree (3) Strongly Disagree (4)
Mean
Standard
Deviation
The Fire Chief is fully committed to health and wellness education. 2.29 0.79
BOSH has at least one member that is fully committed to health and
wellness education.
1.30 0.63

The majority of BOSH stakeholders also agreed that there was at least one BOSH
member who was fully committed to health and wellness education. For this survey item, 96% of
stakeholders agreed, with 76% of stakeholders who strongly agreed. The threshold of a large
majority was exceeded with those who strongly agreed alone. In contrast to the item regarding
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 143

the support of the fire chief, Figure 19 reveals that BOSH stakeholders felt strongly that at least
one health and wellness champion existed in BOSH.
The survey data from Figure 18 and Figure 19 revealed that BOSH stakeholders believed
that HCFR had a good foundation of assets regarding support from its fire chief and at least one
wellness champion. However, the survey data revealed a significant difference in BOSH
stakeholders’ perception of commitment when comparing the fire chief and the champion(s). The
interview data in the following section looked further into the stakeholder’s thoughts and beliefs
about the commitment of the fire chief and BOSH stakeholders as a group.
Interview data. The interviewees shared beliefs that closely matched the survey data.
Interviewees shared perceptions that the fire chief was committed, but about the same number of
interviewees shared perceptions that the fire chief was not committed. In contrast, the large
majority of interviewees expressed strongly that they believed in the commitment of most of the
BOSH members.
One theme was that the very existence of BOSH was proof that the fire chief was
committed to health and wellness. Interviewee 4 stated that “it took a lot to put another bureau in
this department.” Interviewee 6 added that “if the fire chief wasn't committed…I don't know if
we'd have all the resources that we have. They can possibly be reallocated to some other bureau.”
Interviewee 9 felt that “when you get resources, it means there's a commitment there. There's a
commitment to health and wellness.” However, other interviewees felt that the fire chief support
was not a strong as it could be.
Another theme was that the existence of BOSH represents a symbolic show of support,
but that real support from the fire chief is not sufficient. Interviewee 4 felt that BOSH is “a pretty
program…’look what we started’…I think that's how upper management feels about it.” Even
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 144

with a bureau dedicated to the health and wellbeing of a department’s members, some
interviewees stated that they did not “feel…the support from HCFR to fully empower BOSH.”
Interviewee 1 felt that without support from the fire chief, it is hard for any program to “turn the
corner…and really, really jump ahead with a lot of stuff.” Interviewee 5 stated that the fire chief
may be committed “but…to a lesser degree because of our newness…the fact that other
[bureaus] have been around a little longer… we've identified their issues a little better than we've
identified our issues.” Therefore, it is possible that the BOSH members and the fire chief were
operating on separate timelines that had not been communicated to one another.
Suggestions were made with how to increase support from the fire chief. Interviewee 4
stated that it is BOSH’s responsibility to get “chiefs buying into it…realizing the importance of
it.” Interviewee 7 stated that in order to do that, BOSH could work towards “documenting
whenever a peer support member reaches out to anyone, has a contact.” The documentation
would include any interaction, not just crises, to show the true amount of work that is being
done, including prevention. Interviewee 5 suggested that with the data that is collected, BOSH
could ask for “monthly meetings with the fire chief [to] let them know what path we're taking
each and every time, and the cost, and continue to ask for funds.” However, the search for
support should not single out the fire chief, Interviewee 4 felt that eventually it should include
“the right mix of, I don't want to specifically say chiefs, but management. The right mix of
management to empower BOSH. I'm hopeful for that.” In contrast to the mixed feelings about
the commitment from the fire chief, a small number of interviewees shared concern about
commitment from BOSH members.
The goal of the interviews was to assess the commitment of the BOSH members as a
group and not to single any one person out as a champion. The interviewees expressed that the
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 145

BOSH stakeholder group was committed to health and wellness education. Interviewee 8 stated
that in any group there will be a different “level of commitment [in] each one of them…based on
who they are.” BOSH should “really look at who they are, whether or not they're an example of
what they're trying to disseminate to the field.” While most BOSH members “are genuinely
really…interested…some of them are only interested in the overtime that comes along with
it…and others don't really have the time…needed to commit to the program.” However, most
interviewees felt the same way as Interviewee 1 who stated that “everybody is committed.”
Interviewee 2 expressed a common feeling that “for the most part everyone has 100 percent buy
in…or else they wouldn't get involved in it.” Interviewee 8 stated that some of “those that work
in BOSH are 165% committed to the health and wellness program…that's a strange number but
they're very, very committed.” The interview data suggests that BOSH stakeholders as a group
have a high commitment. However, some interviewees gave suggestions on how to take BOSH
stakeholder commitment even further.
Better organization for BOSH stakeholders was a theme for improving commitment.
Interviewee 7 suggested that funding be prioritized “to pay for continuing education or
overtime.” Some interviewees felt that there were not enough chances for PFTs and PSTs to
contribute. Interviewee 1 felt that once funding is secured, it should be used to create
“opportunities for these guys to show a commitment that they do wanna do something.”
However, the BOSH members understood that funding is not always available. Regardless of
where the funding levels are, Interviewee 3 felt that there should be “transparency in the
programs that we're doing and the trainings that we're doing” because, as Interviewee 7 felt,
program updates were “not being communicated enough.” The desire for better organization
could be a result of the lack of staffing resources at BOSH headquarters.
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 146

All three data analysis methods revealed that BOSH had demonstrated assets in fire chief
commitment, but that further development is indicated. The survey and interview data indicated
strong assets in commitment levels from one or more champions, but interview data suggested
that better organization, transparency, and messaging could bring stakeholder commitment even
further. The interview data suggests that better communication and messaging between the chief
(and upper administration in general) and the champion (and BOSH stakeholder group in
general) could increase assets in the commitment levels of both the chief and the champion(s).
Synthesis of Organizational Findings
The document analysis, survey data, and interview data indicate that BOSH had some
organizational assets, but that development is needed in all three factors. The three factors were
the authority to mandate health and wellness education, the financial and staffing resources
needed to implement health and wellness education, and the support from the fire chief and at
least one champion. The document analysis on all three factors demonstrated that BOSH as a
stakeholder group is not starting from scratch and has foundational assets. Furthermore, the data
from documents, surveys, and interviews suggests that the three factors may be linked.
The first factor was authority. Although BOSH is currently not able to mandate education
without approval from the deputy chief level, a history of support to BOSH from the deputy
chief level was discovered for certain proposed initiatives in the past. Examples of previously
supported initiatives include department wide fitness initiatives and safety education. The survey
data regarding authority revealed that a large majority (74%) of respondents agreed that BOSH
should have the authority to mandate health and wellness education, and of the 26% who
disagreed, only 4% strongly disagreed. The interview data supported the survey data.
Interviewees shared that health and wellness education should begin in the academy and be
continually revisited like other programs such as EMT training. However, if the resources and
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staffing are not available to conduct the research and development for initiatives, then even with
authority, BOSH would not be able to implement health and wellness education.
The second factor was resources. Document analysis revealed that BOSH did have a
budget, as well as a full-time staff that worked from headquarters. However, since BOSH was
created in 2014, the budget had not been stable and had been cut each year to support other
programs in HCFR. Additionally, BOSH was still not at the staffing levels that its strategic plan
had laid out. Survey data showed 72% of stakeholders did not agree that BOSH received enough
resources, with 18% who strongly disagreed. Although 28% agreed that BOSH did receive
enough resources, only one respondent (2%) strongly agreed. The interview data provided
context to the survey data. Interviewees stated that they recognized that BOSH existed, had a
budget, and had a full-time staff. Furthermore, almost all interviewees stated that HCFR was
advanced with health and wellness initiatives compared to its neighboring jurisdictions, and this
was done without a survey or interview item prompting such a comparison. However, the
interviewees did point out that training and even health and wellness program related work had
too often come at the expense of the member. Additionally, the interviewees recognized that
BOSH had never been fully funded or staffed and shared feelings that BOSH was not prioritized
the same way other bureaus were. Prioritization for funding and staffing ultimately rests with the
fire chief. Therefore, although the third factor considered commitment from the fire chief and at
least one champion with regard to health and wellness education, it may be that the support of
the fire chief is most important.
The third factor was commitment to health and wellness education from the fire chief and
a champion. The creation of BOSH, its continued existence, and its continued funding
demonstrated commitment. However, the total funding for BOSH, and its priority for funding
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 148

compared to other bureaus, remained low. Additionally, while safety courses were required for
promotion, no preferences for promotion existed for PFTs and PSTs, even though they existed
for special operations members, paramedics, and state certified instructors. Survey data revealed
that 60% of respondents agreed that the fire chief was fully committed to health and wellness
education, with 16% who strongly agreed. However, the number who agreed fell short of the
threshold of a large majority which was 66%. The interviewees shared beliefs and feelings that
might explain why 66% did not agree with the survey item from Figure 18. The feeling that
BOSH was more of a token than a bureau with the buy-in of the chief and upper management
was a theme. Interviewees felt a lack of support and prioritization that would be needed to bring
BOSH into maturity and on par with the other bureaus in HCFR. In contrast, survey and
interview data revealed that stakeholders felt strongly that at least one champion was committed
to health and wellness education.
The data from all three methods indicate that BOSH has foundational assets in all three
organizational factors but that it would benefit by developing those factors. Indeed, the data
revealed that one or more wellness champions existed in the BOSH stakeholder group, there was
historic and growing funding and staffing over the history of BOSH’s existence, and proposed
initiatives from BOSH have historically been approved and implemented throughout the entire
department. Based on the suggestions from the interviewees, the stakeholder goal of a
comprehensive health and wellness education program is possible. By reconsidering the BOSH
budget and using it to maximize trackable interactions of PFTs and PSTs, and then beginning a
regular dialogue with the fire chief about the work BOSH is doing, the commitment from the fire
chief and upper administration may increase. If these recommendations increase the
prioritization of BOSH from the perspective of the fire chief, the budget and staffing could then
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improve. With the proper budget and staffing BOSH could focus on new research and
development proposals, including health and wellness education, which, if approved, could then
be implemented.

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Chapter Five: Solutions, Implementation, and Evaluation
Recommendations for Practice to Address KMO Influences
Knowledge Recommendations
The knowledge influences in Table 17 represent two assumed knowledge influences that
are critical to achieving the stakeholder goal. The analysis on both influences showed that the
stakeholders have some assets in each area, but that development is still needed. These
knowledge influences were identified based on literature from learning theory and will be used to
make recommendations on how to meet BOSH’s stakeholder goal of health and wellness
education for 100% of HCFR.
Anderson et al., (2001) will be used as the framework for knowledge recommendations.
Declarative knowledge (which includes factual and conceptual), procedural knowledge, and
metacognitive knowledge are the three main categories of knowledge used in the framework. For
this analysis, only declarative and procedural knowledge categories are being addressed. Table
17 shows the recommendations for the influences based on theoretical principles.
Table 17

Summary of Knowledge Influences and Recommendations
Assumed Knowledge
Influence
Principle
and
Citation
Context-Specific
Recommendation
BOSH needs to have
the content knowledge
of physical and
behavioral health and
wellness issues that
affect firefighters. (D)
A good education provides people with
solid but general conceptual and
analytical knowledge (Clark & Estes,
2008).
Creating schemata helps learners to
organize declarative knowledge in a
domain (Schraw, Veldt, & Olafson,
2009).
Provide BOSH information
on physical and behavioral
health and wellness
concepts for firefighters
along with a resource
library to include job aids.
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 151

BOSH needs to
understand effective
pedagogy. (P)
Acquiring skills for expertise
frequently begins with learning
declarative knowledge about
individual procedural steps (Clark &
Estes, 2008)
Feedback and modeling increase self-
efficacy (Pajares, 2006).
Provide BOSH members
job aids, modeling, and
corrective feedback on
effective pedagogy.

Developing a health and wellness educational framework and library. Declarative
knowledge includes facts, concepts or underlying principles of an area or field (Krathwohl,
2002). BOSH stakeholders felt they needed to have more education about the physical and
behavioral health and wellness issues that affect firefighters. Clark and Estes (2008) stated that a
good education provides people with solid but general conceptual and analytical knowledge.
Furthermore, creating schemata helps learners to organize declarative knowledge in a domain
(Schraw, Veldt, & Olafson, 2009). This suggests that providing learners with general information
and then organizing that information into concept maps would support their learning. The
recommendation then is to provide BOSH general conceptual information on how to prevent
health and wellness issues such as heart attack, suicide, and cancer, by using a concept map that
can lead BOSH members to research based information about a specific issue. By using the
health and wellness education framework from Figure 3 a virtual library can be created to assist
with initial and continuing education.
Kumar et al. (2011) revealed that using concept maps to assist learners to organize their
prior knowledge of disease pathogenesis helped to integrate new knowledge with existing
cognitive schemata. They demonstrated that a group of students made statistically significant
gains in declarative knowledge when using testable concept maps compared to a control group
that did not. The study supports the recommendation to provide BOSH members with a concept
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 152

map to aid in the building and retention of knowledge about heart attack, suicide, and cancer.
Heart attack, suicide, and cancer are cited in the literature as the top three health and wellness
issues for firefighters (IAFF, 2008; IAFF, 2018; NFPA 2017).
Training BOSH stakeholders on health and wellness educational delivery.
Procedural knowledge is the understanding of the skills and processes involved with a task and
can include techniques or methods (Krathwohl, 2002). BOSH members felt they needed to have
more training in effective pedagogy in order to develop and deliver health and wellness
curricula. Acquiring skills for expertise frequently begins with learning declarative knowledge
about individual procedural steps (Clark & Estes, 2008). Furthermore, Pajares (2006) stated that
feedback and modeling can increase self-efficacy of the learner. Therefore, explaining the steps
of effective pedagogy, modeling the steps, and providing feedback during and after practice
should support learning. The recommendation then is to provide BOSH job aids that outline the
steps for appropriate pedagogy, model effective pedagogy, and provide corrective feedback on
the learners’ skills.
Ericsson, Krampe and Tesch-Romer (1993) revealed that roughly 10,000 hours of
deliberate progressive practice is needed to become an expert. However, they also stated that
immediate feedback is necessary so that practice can continue to be refocused. Modeling is a
way to assist the learner in focusing on the necessary elements of a task (Mayer, 2011; Schraw &
McCrudden, 2006). Clark et al., (2010) assert that effective pedagogy includes providing
declarative knowledge, a demonstration of the expected process, and immediate feedback. The
literature supports the recommendation to provide BOSH with job aids, modeling, and corrective
feedback on pedagogy in order to improve instructional effectiveness.
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 153

Motivation Recommendations
The motivation influences in Table 18 represent two assumed motivation influences that
are critical to achieving the stakeholder goal. The analysis on both influences showed that the
stakeholders have substantial assets in each area, and that reinforcing those assets would be
sufficient. These motivation influences were identified based on literature from motivation
theory and will be used to make recommendations on how to meet BOSH’s stakeholder goal of
health and wellness education for 100% of HCFR firefighters.
The framework that is being used for recommendations is the Clark and Estes (2008) Gap
Analysis Framework. As indicated in Table 18, these influences no do not have an immediate
development need, but instead would benefit from reinforcement as these influences have a
direct impact on achieving the stakeholders’ goal. Table 18 also shows the recommendations for
these influences based on theoretical principles.
Table 18

Summary of Motivation Influences and Recommendations
Assumed
Motivation
Influence
Principle
and
Citation
Context-Specific
Recommendation
Utility Value: BOSH
needs to see the
utility value in
educating firefighters
about health and
wellness at the
beginning, and
throughout their
careers for both the
individual and the
organization.
Rationales that include a discussion of the
importance and utility value of the work
or learning can help learners develop
positive values (Eccles, 2006; Pintrich,
2003).
Provide BOSH with
rationales through
discussion about the
importance of educating
firefighters on health and
wellness at the beginning
and throughout their
careers.
Attribution: BOSH
needs to understand
Learning and motivation are enhanced
when individuals attribute success or
Develop a tracking tool of
BOSH health and
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that firefighter health
and wellness can be
changed through
BOSH’s educational
efforts.
failures to effort rather than ability.
(Anderman & Anderman, 2009).
wellness preventive
educational efforts and
provide feedback during
meetings.
Highlight the importance of preventability of heart attack, suicide, and cancer
death. Utility value is a measure of how well a task fits into one’s long term goals (Eccles,
2009). BOSH stakeholders expressed high value, for both the individual and the organization, of
educating firefighters on health and wellness issues at the beginning of, and throughout, their
careers. Rationales that include a discussion of the importance of the work can help learners
develop positive values (Eccles, 2006; Pintrich, 2003). This suggests that engaging stakeholders
in routine dialogue of the evidence that heart attack, suicide, and cancer deaths are largely
preventable can increase stakeholder utility value. The recommendation then is to coordinate
routine meetings where BOSH stakeholders are provided with rationales through discussion to
reinforce the importance of educating firefighters on health and wellness at the beginning of, and
throughout, their careers.
Preventable lifestyle factors are prevalent in heart attacks (Kales, et al., 2007;
Kunadharaju et al., 2011), suicide (Cavanagh, Carson, Sharpe & Lawrie, 2003; Harris &
Barraclough, 1997; Henderson et al., 2016; Ratey & Hagerman, 2008), and cancer (Albini et al.,
2012; Anand et al., 2008; Carroll, 1998, Larsson & Masucci, 2016; Seyfried, 2014). Indeed,
Soteriades et al. (2011) concluded that heart attack in firefighters is not random; 90% of
firefighters that die of heart attack have coronary heart disease. Additionally, between 45% and
90% of those that commit suicide have at least one diagnosable, and thus treatable, psychiatric
disorder (Cavanagh, Carson, Sharpe & Lawrie, 2003; CDC, 2018; Harris & Barraclough, 1997),
and research suggests that mental health is controllable with lifestyle adjustments (Carey et al.,
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 155

2011; Haddock et al., 2015; Henderson et al., 2016; Ratey & Hagerman, 2008; Sapolsky, 2004).
Lastly, up to 90-95% of cancers are now understood to be caused by lifestyle or environmental
issues and thus preventable (Anand et al., 2008). Therefore, even though the fire service has
known occupational risks involved, the top three health and wellness issues for firefighters must
be considered as preventable lifestyle health issues as well. Since education is the foundation for
initiating and maintaining change (Clark & Estes, 2008), then highlighting the preventability of
heart attack, suicide, and cancer should increase utility value of health and wellness education.
Highlight the role of effort by tracking the impact of preventive education and
interactions. Attribution theory is focused on understanding how individuals or organizations
frame the cause associated with an effect in their environment (Anderman & Anderman, 2006).
Based on the belief of what is causing a specific effect, an individual or organization may
conclude that they have more or less control of their environment (Anderman & Anderman,
2006). Collectively, BOSH felt that firefighter health and wellness could be changed through
BOSH’s educational efforts. Anderman and Anderman (2006) state that learning and motivation
are enhanced when individuals attribute success or failures to effort rather than ability. This
suggests that a way to identify and measure effort must be developed first, and then success must
be attributed to that effort. The recommendation then is to develop a tracking tool for health and
wellness preventive educational efforts and provide feedback during meetings to reinforce
attribution of BOSHs efforts.
When the ability is there in the learner, knowledge and performance can improve from
proper education and training (Aguinis & Kraiger, 2009; Pajares, 2006). Education and training
can improve physical-health in firefighters (Banes, 2014; Elliot et al., 2007; McDonough,
Phillips, & Twilbeck, 2015). Behavioral health can also be improved with proper education and
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 156

training (Ratey & Hagerman, 2008; Smith et al., 2011; Wagner, & Martin, 2012). However,
forcing BOSH stakeholders to deliver education when they do not want to, and to individuals
they do not want to, is not the goal. To increase attribution, Pintrich (2003) suggests providing
opportunities to exercise choice and control. BOSH stakeholders should be provided a
framework to allow them to conduct preventive education with others in a consensual manner,
when they want to, but be encouraged to report the interactions. Tracking preventive educational
interactions would allow BOSH stakeholders to review their efforts and increase attribution to
firefighter health and wellness.
Organization Recommendations
The organization influences in Table 19 represent three assumed organization influences
that are critical to achieving the stakeholder goal. The analysis on these influences showed that
there are varying degrees of assets in each area but that the assets needed development. These
organization influences were identified based on literature from organizational theory as well as
context specific literature and will be used to make recommendations on how to meet BOSH’s
stakeholder goal of health and wellness education.
The framework that is being used for recommendations is the Clark and Estes (2008) Gap
Analysis Framework. Recommendations for the organization influences focus on policies,
resources, and processes. Table 19 shows the recommendations for the influences based on
theoretical principles.
Table 19

Summary of Organization Influences and Recommendations
Assumed
Organization
Influence
Principle
and
Citation
Context-Specific
Recommendation
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BOSH needs to be
given authority to
prioritize health and
wellness across
departmental
programs. (Policies)
Rules, policies, standards, and standard
operating procedures limit individual
discretion and help ensure that behavior
is predictable and consistent (Bolman &
Deal, 2013).
Draft and submit proposals
that empower BOSH to
prioritize health and
wellness across
departmental programs.
BOSH needs to be
funded and staffed
appropriately for
developing and
implementing health
and wellness
education. (Resources)
Staying current with the field’s research
and practice is correlated with increased
student learning outcomes (Waters,
Marzano & McNulty, 2003).
Organizational effectiveness increases
when leaders ensure that employees have
the resources needed to achieve the
organization’s goals. (Waters, Marzano
& McNulty, 2003).
Propose a BOSH position
that has the resources and
support to stay current
with research in order to
develop and implement
health and wellness
education which is one of
the organization’s goals.
BOSH needs to have
the support of the fire
chief and one or more
champions for
generating buy-in.
(Processes)
Effective leaders are aware of the power
of influence and its impact on the change
process within an organization. (Conger
1991; Denning, 2005; Lewis, 2011).
Develop messaging and
reporting products to
leverage the influence of
the fire chief and one or
more champions to
generate buy-in.

Gaining authority to integrate health and wellness education into HCFR. Authority
is the rights or power granted to an entity to command action and expect that the action will be
carried out (Robins & Judge, 2010). BOSH felt that HCFR needed to give more authority to
BOSH to prioritize health and wellness across departmental programs. Bolman and Deal (2013)
explain that rules, policies, standards, and standard operating procedures limit individual
discretion and help ensure that behavior is predictable and consistent. The recommendation then,
is to draft and submit proposals that empower BOSH to prioritize health and wellness across
departmental programs.
The National Fire Protection Association (NFPA) is a non-profit organization that
recommends industry standards for the fire service. While the standards offered by NFPA are not
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 158

required to be adopted, the intent is to anticipate and amend standards as necessary for fire
departments to adopt when they are ready to do so. NFPA offers two major industry standards
that focus on health and wellness. NFPA 1500 recommends that a fire department establish a
health and fitness program in order to develop and maintain fitness of its members (NFPA,
2012). It also recommends providing a behavioral health program and a wellness program that
provides prevention strategies that, whenever possible, is research based and peer reviewed.
NFPA 1583 recommends that fire departments provide health promotion education as part of a
health and wellness program. The education should include health risk reduction, cardiovascular
risk reduction, general health maintenance, and prevention of occupational illness, injuries,
accidents and fatalities (NFPA, 2015).
The International Association of Fire Fighters (IAFF) and the International Association
of Fire Chiefs (IAFC) partnered in the mid 1990’s to deliver a continual message about health
and wellness (IAFF, 2008). The partnership was named the IAFF/IAFC Joint Labor Management
Wellness-Fitness Initiative (WFI) and began with a focus on medical evaluation, fitness, and
injury and medical rehabilitation. There are two main features of the IAFF/IAFC WFI. The first
is the Peer Fitness Trainer (PFT) program, and the second is the Peer Support Team program
(PST) (IAFF, 2008). The PFT program is recommended to be an educational and rehabilitative
program, not a punitive one. Specifically, the WFI suggests PFTs should be educating firefighter
recruits in the academy, as well as during their careers, about starting and maintaining fitness and
wellness.
The second feature is the Peer Support Team program. The WFI behavioral support
program started with the Critical Incident Stress Management model (IAFF, 2008). However,
after research that the CISM model may be ineffective and even harmful in certain situations
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 159

(Rose et al., 2002; Van Emmerik et al., 2002), the WFI switched to the current PST model
(IAFF, 2017). The PST model is intended to provide initial behavioral health support, education,
and guidance about available behavioral health resources to peers. The NFPA and the
IAFF/IAFC-WFI do not create policy for fire departments. However, both institutions suggest
that physical and behavioral health and wellness education should be implemented. Therefore,
the context specific literature supports the recommendation to draft and submit proposals that
empower BOSH to prioritize physical and behavioral health and wellness education across
departmental programs.
Bringing health and wellness research from the “ivory tower to the hose tower.”
Organizational effectiveness increases when leaders ensure that employees have the resources
needed to achieve the organization’s goals (Waters, Marzano & McNulty, 2003). BOSH
stakeholders felt that BOSH needed more resources to develop and implement health and
wellness education. Resources refer to the money, human capital, and other administrative
support necessary to complete an initiative (Robins & Judge, 2010). When developing wellness
education, NFPA (2012) suggest that fire departments use research-based material whenever
possible. Indeed, using current research is correlated with increased student learning outcomes
(Waters, Marzano & McNulty, 2003). To develop and deliver effective and accurate health and
wellness education, BOSH needs to have someone who can stay current on industry research,
review and synthesize it, and then relay that research to firefighters. Ideally, this would be a
firefighter, of any rank, who has the ability to review industry research, and then convey that
research to their fellow firefighters in a way that relates to firefighter schema. The
recommendation then is to propose a BOSH position that has the resources and support to stay
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 160

current with research in order to develop and implement physical and behavioral health and
wellness education which is one of the organization’s goals.
Staying current with research is a critical factor for evidence-based management.
Rousseau (2006) stated that evidence-based management involves using current generalizable
knowledge and applying it to localized knowledge of an organization. She referred to
generalizable knowledge as “Big E Evidence” and local knowledge as “little e evidence.”
Furthermore, successfully introducing “Big E Evidence” to the local organization works best as a
collaborative effort between researchers and practitioners (Rousseau, 2006). The local expert
(practitioner) should seek out relationships with local, state, and national experts (researchers)
that can work with the practitioner to summarize the most current research knowledge. However,
this involves identifying, and perhaps developing, a local expert who can understand the research
and engage with both researchers and members of the practitioner’s organization. This model
could be used by BOSH to research and develop health and wellness education. Although
research and development costs money, the return on investment for wellness programs seems
worth it.
Research on workplace wellness programs suggests a positive return on investment
(ROI). Baicker, Cutler and Song (2010) explain that on average, for every dollar spent on a
workplace wellness program, the ROI is three dollars. Kuehl et al., (2013) found that ROI on
comprehensive firefighter wellness programs was anywhere from one to four and a half dollars
(1- 4.6) for every dollar spent. More recently, the IAFF/IAFC-WFI published a finding that fire
service specific research on wellness programs report a minimum ROI of at least two dollars on
every dollar spent, with those returns beginning as soon as the second year (IAFF, 2018). From a
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 161

return on investment perspective, the literature supports the recommendation of ensuring that
BOSH has the resources needed to develop and implement health and wellness education.
Improve messaging and reporting to maximize chief and champion influence. BOSH
stakeholders felt that BOSH needed to have more support from the fire chief but that it had
sufficient support of one or more health and wellness champions. Effective leaders are aware of
the power of influence and its impact on the change process within an organization (Conger,
1991; Denning, 2005; Lewis, 2011). The recommendation then is to develop messaging and
reporting products to leverage the influence of the fire chief to generate buy-in.
Kuehl et al. (2013) conducted a study to see what factors were responsible for the
successful adoption of a fire department wellness program. To do this the authors looked at a
past study called Promoting Healthy Lifestyles: Alternative models’ effects (PHLAME) (Moe et
al., 2002). The PHLAME study was an effort to get fire departments to adopt a wellness
program. Kuehl et al. (2013) compared 12 departments that successfully implemented a wellness
program to 24 departments that did not. Of the departments that did successfully implement the
wellness program the two main factors were the “champion” and the “chief” (Kuehl et al., 2013).
Having a wellness enthusiast that was passionate about the program regardless of position or pay
and a chief that was supportive of the program and the champion were critical to implementation.
The study by Kuehl et al. (2013) is the foundation for the recommendation to develop messaging
and reporting products to leverage the influence of the fire chief and one or more champions to
generate buy-in to health and wellness education initiatives throughout HCFR.
Integrated Implementation and Evaluation Plan
Implementation and Evaluation Framework
The model being used to generate the implementation and evaluation framework is the
New World Kirkpatrick Model (Kirkpatrick & Kirkpatrick, 2016). In this model, Kirkpatrick’s
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Four Levels of Training Evaluation are updated for the modern economy, but the core evaluation
levels are the same. The key is that the New World Kirkpatrick Model is set up in reverse order
starting from the ultimate goal of the stakeholder group which is Level 4. By going in reverse
order, the model asks the user to identify which behaviors (Level 3) may lead to the ultimate
goal. Then, the user must identify what training (Level 2) would lead to the desired behaviors.
Finally, the user must assess the reaction (Level 1) about the training being delivered. The New
World Kirkpatrick Model keeps the focus on the end result of why the training is being done in
the first place (Kirkpatrick & Kirkpatrick, 2016).
Organizational Purpose, Need, and Expectations
The organizational mission of BOSH is to develop and maintain an innovative
occupational safety and health program that fosters a safe work environment, wellness, and
healthy lifestyle. One of the major goals of BOSH is that 100% of the members of HCFR will
receive physical and behavioral health and wellness education every year of their career. Heart
attack, suicide, and cancer are the top three health and wellness issues for firefighters (NFPA,
2017) during their careers, and all three are considered to be mostly preventable.
The problem is that the firefighters in HCFR have no access to heart attack, suicide, or
cancer prevention education, either through the Maryland Fire and Rescue Institute (MFRI), or
through HCFR. This is why the stakeholder goal for BOSH is to develop a minimum of 16 hours
of curriculum on physical and behavioral health and wellness that is applicable to 100% of the
members of the department. The reason for this goal is that without providing initial and
continuing education on how to prevent heart attack, suicide, or cancer, BOSH cannot reasonably
expect to foster wellness and a healthy lifestyle within HCFR.
This research examined the knowledge, motivation, and organizational factors that may
be needed to develop an initial and continuing health and wellness educational curriculum for
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 163

HCFR. A solution has been proposed for each knowledge, motivation, and organizational factor.
The proposed solutions, if carried out comprehensively, should produce the desired outcome of
educating 100% of HCFR members, in every year of their career, on physical and behavioral
health and wellness.
Level 4: Results and Leading Indicators
Table 20 shows the proposed Level 4: Results and Leading Indicators in the form of
outcomes, metrics and methods for both external and internal outcomes for BOSH. The external
observations and measurements refer to information that originates from outside of HCFR. The
internal observations and measurements refer to information that originates within HCFR.
Table 20

Outcomes, Metrics, and Methods for External and Internal Outcomes
Outcome Metric(s) Method(s)
External Outcomes
1. Increased public
approval of HCFR or
BOSH health and
wellness initiatives.
Frequency of HCFR or BOSH
in press or industry related
media coverage.
Track frequency of HCFR or
BOSH mentions in press or
industry related media.
2. Increased concessions
from health insurance
agencies.
Value of concessions given
from health insurance
providers.
Track value of concessions
given to HCFR by health
insurance providers.
3. Increased number of
health and wellness
courses offered by the
state sponsored training
agency- MFRI.
Number of physical or
behavioral health and wellness
courses offered in MFRI course
catalogue.
Track the course catalogue of
MFRI.
Internal Outcomes
4. Decreased percentage
of firefighters that flag
Aggregate percentage of
firefighters that flag on critical
health screens (i.e. obesity,
Solicit data from the medical
assessment contractor.
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 164

on critical health
screens.
hypertension, blood sugar,
cholesterol, etc).
5. Increased amount of
physical and behavioral
health and wellness
education in HCFR.
4a. Number of hours dedicated
to physical and behavioral
health and wellness in HCFR’s
fire academy (initial education).
Compare training class academy
schedules.

4b. Number of physical and
behavioral health and wellness
courses that are available to
firefighters after the academy
(continuing education).
Track courses that exist as
continuing education for veteran
firefighters.
6. Increased employee
satisfaction with BOSH
health and wellness
education.
8a. Survey results. 8a. Compare survey results on a
continuous basis.

8b. Positive feedback from
HCFR members
8b. Set aside time for one-on-
one or whole shift conversations
in the field regarding BOSH
health and wellness education.
Level 3: Behavior
Critical behaviors. The stakeholders of focus are the members of the Bureau of
Occupational Safety and health (BOSH). The first critical behavior is that BOSH stakeholders
must conduct preventive or educational interactions with HCFR members in the field. At a
minimum, each stakeholder should conduct at least one preventive interaction per month (i.e.
sharing a news article with a shift). Ideally, the large majority of total interactions that BOSH
stakeholders conduct with HCFR members should be preventive or educational. However, some
responsive interactions are expected as well. Ideally, less than half of all interactions might
consist of assisting an HCFR member in need of something that is not a physical or behavioral
crisis (i.e. a request for information on reducing back pain, or on meditation techniques). A small
number of responses to crises are expected (i.e. assisting an HCFR member to pass a mandatory
annual physical exam or assisting a member in emotional crisis after an emergency response).
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 165

The second critical behavior is that BOSH stakeholders should develop educational
products. An educational product might consist of a job-aid, a summary of pertinent research, or
even a workout of the week. Educational products should be developed for both physical and
behavioral health and wellness.
The third critical behavior is that BOSH stakeholders develop educational modules on
physical and behavioral health and wellness. Modules must address the prevention of heart
attack, suicide, or cancer, by presenting information on lifestyle factors of physical activity,
nutrition, or mental activity. The modules should be a minimum of 15 minutes in length and
follow the proper pedagogical process. The specific metrics, methods, and timing for each of
these behaviors appear in Table 21.
Table 21

Critical Behaviors, Metrics, Methods, and Timing for Evaluation
Critical Behavior Metric(s) Method(s) Timing
1. Conduct preventive or
educational interactions
with HCFR members.
1a. Number of reported
preventive or educational
interactions from BOSH
stakeholders to HCFR
members.
1a. Team lead shall
analyze peer fitness
interactions.
Ongoing-
Monthly

2a. Team lead shall
analyze peer
support team
interactions.
Ongoing-
Monthly
2. Develop products by
researching and reporting
on physical and behavioral
health and wellness issues
that arise in news, research
journals, and industry
specific media.
Number of physical or
behavioral health and
wellness products created by
BOSH stakeholders and
disseminated to HCFR.
Team lead shall
track products
created by BOSH
stakeholders.
Ongoing-
Monthly
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 166

3. Develop educational
modules on physical and
behavioral health and
wellness.
Number of physical or
behavioral health and
wellness educational
modules developed by
BOSH stakeholders and
approved for dissemination
to HCFR members.
Team lead shall
track educational
modules produced
by BOSH
stakeholders.
Ongoing-
Quarterly

Required drivers. BOSH stakeholders require the support of their direct supervisors and
the organization to reinforce what they learn from specialized physical or behavioral health and
wellness training and to encourage them to apply what they have learned to educating the
members of HCFR. Rewards should be established for achievement of performance goals to
enhance the organizational support of BOSH stakeholders. Table 22 shows the recommended
drivers to support critical behaviors of BOSH stakeholders.
Table 22

Required Drivers to Support Critical Behaviors
Method(s) Timing
Critical
Behaviors
Supported
1, 2, 3 Etc.
Reinforcing

Provide BOSH stakeholders with continuing education on
physical and behavioral health and wellness concepts.
Quarterly 1, 2, 3
Provide BOSH with a health and wellness resource library to
include research articles and job aids.
Ongoing 1, 2, 3
Provide BOSH members with continuing education, modeling,
and corrective feedback on effective pedagogy.
Quarterly 1, 2, 3
Provide BOSH members with job aids on effective pedagogy. Ongoing 1, 2, 3
Encouraging

HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 167

Remind BOSH stakeholders about the usefulness of educating
firefighters on health and wellness at the beginning and
throughout their careers.
Quarterly 1, 2, 3
Remind BOSH stakeholders that they can change firefighter
health and wellness through educational efforts.
Quarterly 1, 2, 3
Feedback and coaching from team lead. Ongoing 1, 2, 3
Messaging from the Fire Chief to HCFR about the importance
of health and wellness and the work of BOSH stakeholders
Quarterly 1, 2, 3
Rewarding

Performance incentive when BOSH stakeholders develop and
implement health and wellness education.
Project-based 1, 2, 3
Public acknowledgement at team meetings, health and wellness
events, via email, or through other media.
Ongoing 1, 2, 3
Monitoring

Team lead can create opportunities at meetings for BOSH
stakeholders to share success stories.
Quarterly 1, 2, 3
Team lead can conduct self-efficacy surveys on critical
performance factors and health and wellness topics.
Bi-annually 1, 2, 3
Team lead can assess the performance of BOSH stakeholders
with frequent, quick checks to monitor progress and make
adjustments if results do not match expectations at that time.
Ongoing 1, 2, 3

Organizational support. In order to ensure that the drivers listed in Table 22 are
implemented on a continuous basis, several organizational factors must be accounted for. First,
BOSH must have published rules, policies, standards, and standard operating procedures that
empower BOSH stakeholders to prioritize health and wellness across departmental programs.
Secondly, BOSH must obtain the financial and human resources needed to develop and
implement health and wellness education. Finally, BOSH must leverage the influence of the fire
chief and one or more champions through messaging and reporting products to generate buy-in.
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 168

A monthly product will be developed that allows the fire chief and one or more champions to
communicate with the department, and a monthly and yearly report on key physical and
behavioral health and wellness information will be developed for the fire chief and the
department as appropriate.
Level 2: Learning
Learning goals. Following the completion of the recommended solutions, BOSH
stakeholders will be able to:
1. Provide an explanation of how lifestyle relates to health and wellness. (D)
2. Provide an explanation of how physical activity relates to lifestyle health issues. (D)
3. Provide an explanation of how nutrition relates to lifestyle health issues. (D)
4. Provide an explanation of how mental activity relates to lifestyle health issues. (D)
5. Differentiate between heart attack, suicide, and cancer risk factors. (D)
6. Determine methods to prevent heart attack, suicide, and cancer. (D)
7. Carry out a preventive interaction role-play (physical or behavioral health). (P)
8. Judge a research article for its worthiness and write a one paragraph summary. (P)
9. Design a template of an educational module. (P)
10. Value the importance of initial and continuing education in the change process. (Value)
11. Attribute success or failure to effort if the ability to perform is present. (Attribution)
Program. The learning goals listed in the previous section will be achieved with a train-
the-trainer program. The program will provide BOSH stakeholders with a shared understanding
of the conceptual and procedural knowledge influences, and the motivation influences.
Additionally, the program will have a portion dedicated to job-aid familiarization. Synchronous
learning will be conducted in person over the course of two days (16 hours). The first day will
consist of two modules on knowledge, and the second day will consist of a module on motivation
and job-aid familiarization. A four-hour asynchronous learning portion will include using the
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 169

online resource library, assigned reading, and practice using job-aids. In addition, a four-hour
asynchronous assessment module will be included. The program will be a total of 24 hours.
The knowledge portion includes two areas. The first knowledge area will introduce
physical and behavioral health and wellness issues and risk factors using the framework from
Figure 3. The introduction of a health and wellness framework is meant to support a shared
understanding of the circumstances among the stakeholders. Included will be an overview of
Figure 5 which introduces a model of assessment on what can and cannot be changed,
knowledge and motivation of the identified deficiency, and the relationship between the
individual and the organization. A summary on heart attack, suicide, and cancer research, as well
as prevention strategies using physical activity, nutrition, and mental activity will be presented.
The program will use fire service specific and general population statistics and research.
The second knowledge area will address proper pedagogical techniques. Included will be
a framework for a shared understanding of how to design and deliver educational modules, as
well as how to conduct ad-hoc personal or group educational interactions. Role-play and lesson
delivery practice will be included during in-person portions of the program, and feedback and
coaching will be provided.
The motivation portion will be included during the in-person training and will address
utility value and attribution. The learners will be exposed to theoretical and empirical evidence
of how utility value and attribution affect effort and thus outcomes. Learners will have the
opportunity to share success stories with each other. Additionally, a message of encouragement
and importance from the Fire Chief via letter, video, or in person will be included. A before and
after survey will be used to capture stakeholders’ feelings of utility value and attribution.
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 170

Job-aid familiarization will be the last portion of the in-person training. Job-aids will
include key concepts of physical and behavioral health and wellness, key processes of pedagogy,
key factors of an effective instructor, the role of utility value and attribution, and the goals,
needs, and how tracking will occur. After reviewing the job-aids, the learners will be
familiarized with the online resource library and online assessment modules for the
asynchronous portion.
After the in-person training, learners will complete the asynchronous training and
assessments. The asynchronous portion will give stakeholders time to explore the resources and
conduct additional learning at their own pace. Learners will use the asynchronous assessment to
demonstrate their knowledge of health and wellness concepts and their knowledge of the
pedagogical process. Also, learners will demonstrate their ability to use the job-aids provided.
Finally, learners will demonstrate their ability to synthesize information from research or news
articles by writing a summary of the readings. A certificate of completion will be presented to
each learner once the asynchronous section is complete which includes review and approval of
the summary of the readings. Table 23 outlines the synchronous and asynchronous portions of
the train-the-trainer program.
Table 23

Components of Learning
Train-the-Trainer Program
Synchronous
Conceptual Procedural Motivation Job-Aids
Framework Design Utility Value Knowledge 1
Physical Activity Delivery Attribution Knowledge 2
Nutrition Practice Success Stories Motivation
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 171

Mental Activity Feedback Chief’s Message
Needs, Goals,
and Tracking
Asynchronous
Resource Library
Familiarization
Resource Library
Familiarization
Assigned Reading
Job Aid
Practice
Conceptual
Knowledge
Assessment
Conceptual
Knowledge
Assessment
Reading Synthesis
Assessment
Job Aid
Assessment

Evaluation of the components of learning. Kirkpatrick and Kirkpatrick (2016) list five
components of learning: knowledge, skill, attitude, confidence, and commitment. These five
components of learning are critical if learners are to apply knowledge to solve problems. The
right motivation to apply the knowledge to solve problems is also necessary. The Clark and Estes
(2008) KMO model aligns well with the Kirkpatrick and Kirkpatrick (2016) five components of
learning. Knowledge and skill from Kirkpatrick and Kirkpatrick align with knowledge from
Clark and Estes. Attitude, confidence, and commitment from Kirkpatrick and Kirkpatrick align
with motivation from Clark and Estes. Table 24 lists methods or activities that will be used to
evaluate the five components of learning as well as the timing of evaluation.
Table 24

Evaluation of the Components of Learning for the Program
Method(s) or Activity(ies) Timing
Declarative Knowledge “I know it.”

Knowledge checks through discussion. Throughout in-person training.
Knowledge checks using multiple choice and fill in
the blank.
Asynchronous portion of the training.
Procedural Skills “I can do it right now.”

Role play to demonstrate educational interactions
with others.
During in-person training.
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 172

Practice delivering micro lessons to a group. During in-person training.
Correctly ordering the educational process. Asynchronous portion of the training.
Summarizing research or news articles about health
and wellness.
Asynchronous portion of the training.
Attitude “I believe this is worthwhile.”

Pre and post survey about value of mission. Before and after in-person training.
Observations of participant actions and statements. During in-person training.
Discussing value of the mission. During in-person training.
Confidence “I think I can do it on the job.”

Self-efficacy survey. After in-person training.
Discussions following in person modules. During in-person training.
Commitment “I will do it on the job.”

Discussions following in person training. After in-person training.
Develop individual action plan. Asynchronous portion of the training.

Level 1: Reaction
Kirkpatrick and Kirkpatrick (2016) explain that Level 1 evaluation should be simple,
inexpensive, and designed to determine if the program content and the person delivering the
program were well received. Surveys, observation, and brief check-ins with the learners can be
used to evaluate engagement, relevance, and satisfaction which make up Level 1 evaluation
(Kirkpatrick & Kirkpatrick, 2016). Learner engagement can easily be observed during a course.
However, feedback for relevance and customer satisfaction may change if that information is
collected immediately after a training or if it is collected after allowing for a period of reflection
(Kirkpatrick & Kirkpatrick, 2016). Therefore, it is important to consider whether the learners
have the experience to judge the relevance of the training, and whether they are comfortable
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 173

enough to give honest feedback about their satisfaction with the course material and instructor.
In order to become a Peer Fitness Trainer or a Peer Support Team member in HCFR, a firefighter
has to have completed their probationary year, but usually have at least a few years of experience
in the department before being invited to join either team. Most Peer Fitness Trainers and Peer
Support Team members in HCFR have more than five years of experience and are considered
veteran firefighters. Therefore, it is assumed that the ability to determine relevance of training is
present in the firefighter, and the comfort to answer honestly about course material and instructor
quality is also present. Table 25 shows the methods of measuring engagement, relevance, and
customer satisfaction, as well as the timing for capturing that data.
Table 25

Components to Measure Reactions to the Program
Method(s) or Tool(s) Timing
Engagement
Observation by instructor During in person training
Pulse checks In between modules of in-person training
Course evaluation survey Immediately after in-person training
Relevance
Course evaluation survey
1a. Immediately after in-person training
1b. Immediately after asynchronous portion
Customer Satisfaction
Course evaluation survey
1a. Immediately after in-person training
1b. Immediately after asynchronous portion
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 174

Evaluation Tools
Immediately following the program implementation. One portion of the training
program is in person, and one portion of the training program is asynchronous. The
asynchronous portion will use interactive tools for the learners to apply what they learned during
the in-person portion. This will include pass or fail conceptual knowledge assessments, pass or
fail procedural knowledge assessments and writing assignments that will be provided with
feedback by the instructor. The learning management system will be able to provide data on each
user regarding the time it took to complete each assessment and to complete the writing
assignment. In order to complete the asynchronous portion, a brief evaluation survey will be
required to gather input on the relevance and customer satisfaction of the asynchronous material,
as well as the attitude, confidence, and commitment of the learner. The evaluation survey will be
similar to the one used after the in-person portion.
The evaluation to be used after the in-person portion is shown in Appendix G. The in-
person evaluation will include a short assessment of the learner’s confidence, as well as their
ability to recall key points of the training. The assessment will ask the learner to identify
concepts of physical and behavioral health and wellness, as well as the procedures of proper
pedagogy. The assessment will ask the learners about how stimulating the material was, the
relevance of the material, and their satisfaction with the training. Additionally, the assessment
will also gently probe the learner’s attitude, confidence, and commitment regarding health and
wellness education.
Delayed for a period after the program implementation. A follow up evaluation will
be administered approximately 90 days after the training delivery (Appendix H). The items
include Likert-type responses and short open-ended responses. The purpose of the follow up
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 175

evaluation seeks to assess the stakeholders’ feelings of training relevance, confidence in what
was learned, and behavior change. Relevance of the training (Level 1) will be evaluated by
asking learners about whether they feel their understanding improved. Confidence (Level 2) will
be evaluated by asking learners about their ability to deliver health and wellness education.
Behavior (Level 3) will be evaluated by asking learners about the number of interactions they
have completed, their use of job aids, and their experience with research and development.
Finally, an open-ended item asking for feedback on what would help the stakeholder to become a
better health and wellness educator is included.
Data Analysis and Reporting
The organizational goal for HCFR is to educate 100% of firefighters on physical and
behavioral health and wellness. To achieve that goal, stakeholders need to demonstrate the
ability to educate their peers and create educational products and modules for course
development. The leader of the physical and behavioral health and wellness program will track
the number of interactions conducted by each team every month. Additionally, educational
products and modules will be tracked quarterly. A report will be generated monthly on the
number of educational interactions conducted by each team. As educational products and
modules are developed, they will be reviewed by the program leader and shared with the
department either in the library or through in-person or online training delivery. An annual report
will also be generated. The chart in Appendix I is a simple example of how the interaction,
product, and module reporting could be captured and assessed against a target. Assessments of
competence and confidence will be conducted in person during monthly and quarterly team
meetings.
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 176

Summary
The New World Kirkpatrick Model (Kirkpatrick & Kirkpatrick, 2016) guides the user of
the model on how to conduct training evaluation in the modern workforce. The model maintains
Kirkpatrick’s Four Levels of training evaluation which are used in reverse from Level 4 to Level
1 in order to design training evaluation with the end goal in mind. In this chapter, the planning,
implementation, and evaluation recommendations for BOSH to achieve its organizational goal
were presented. First, the assumed knowledge, motivation, and organizational needs were
presented, along with associated recommendations that were supported by theoretical or
empirical research. Next, the organizational purpose and expectations were reviewed. Finally, a
plan was presented to evaluate the successful completion of the stakeholder and organizational
goals for BOSH to include results (Level 4), behavior (Level 3), learning (Level 2), and reaction
(Level 1).
The New World Kirkpatrick Model (Kirkpatrick & Kirkpatrick, 2016) suggests that
evaluation, and intervention, should not wait until implementation is complete. Instead,
evaluation should be continuous so that adjustments can be made as soon as needs are identified
through evaluation. Therefore, the expectation for using this framework of evaluation is a
targeted analysis of meaningful data on all four levels of evaluation (results, behavior, learning,
and reaction) for the proposed KMO recommendations. A draft version of a data analysis tool for
Level 3 can be found in Appendix I.
The benefit of targeted data analysis for evaluating the implementation of a program is
twofold. The data can help to address why something may not be working, but also provide
support if it is working (Kirkpatrick & Kirkpatrick, 2016). With well-tuned data collection and
analysis tools for all four levels, interventions can be made in a timely and precise manner.
Alternatively, if the implemented program is successful, then the data can be used to support the
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 177

publicizing or propagating of the program for other organizations that wish to use it (Kirkpatrick
& Kirkpatrick, 2016). Therefore, the ultimate expectation of the evaluation of this program is to
share a successful physical and behavioral health and wellness educational model with other fire
service organizations.
Future Research
Health and wellness education and prevention efforts have grown in the fire service even
since the start of this research. This research was specifically dedicated to determining what was
hindering health and wellness education in HCFR, and what factors may be needed to develop
health and wellness education. However, throughout the course of the literature review and the
organizational specific data gathering, three areas of future research emerged as possible areas
for both HCFR and the U.S. fire service.
First, longitudinal research should be used to determine how initial health and wellness
academy education is both perceived and valued by HCFR firefighters during the course of their
career. It would be valuable to know whether health and wellness education delivered in the
academy becomes part of firefighter schema, and whether or not firefighters who received initial
education on health and wellness will believe it led to lifestyle changes from before the time they
had the education to after. Research of this nature could help defend or counter the argument for
initial health and wellness education in the fire academy.
Second, research on departmental health data metrics should be used to determine what
trends, if any, can be correlated to initial health and wellness education. Aggregated health data
for the entire department could provide statistics on key health metrics that are linked to physical
and behavioral health and wellness issues. The research should consider historic departmental
data that is adjusted for age and other factors, as well as regional and national data if that is
available. Research on health metric trends from a time when there was no health and wellness
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 178

education, to a time period when there was could help HCFR understand the economic impact of
initial health and wellness education.
Third, research should consider the use of physical and behavioral support programs
when initial health and wellness education is in place. HCFR offers both a Peer Fitness Team
and a Peer Support Team as health and wellness resources to its members. Those teams exist as a
first line of support for firefighters who may seek to increase their fitness, nutrition, or mental
resilience. It would be valuable to know whether initial health and wellness education increases
first line support program usage among HCFR firefighters, and if possible, what corresponding
increase or decrease in external professional physical or behavioral support is used.
Finally, ongoing research should be conducted to assess health and wellness education in
fire departments across the United States. Health and wellness programs that offer support
services such as Peer Fitness Teams and Peer Support Teams do not guarantee that initial or
continuing health and wellness education is being delivered to firefighters. Research of this
nature should seek to determine what topics of health and wellness education are being
delivered; how much time in relation to the total length of the fire academy is being dedicated to
health and wellness education, and; what qualifications the individual or group has that is
delivering the information. It would be valuable to the U.S. fire service stakeholders to know
what is currently being done across the industry, and what changes, if any, should be considered.
Conclusion
The purpose of this research was to determine knowledge, motivation, and organizational
factors that might have been hindering health and wellness education from being developed and
delivered in HCFR. Initial and continuing health and wellness education is of interest to HCFR
and BOSH because heart attack, suicide, and cancer have become major health and wellness
issues for the fire service. Waiting for MFRI or other entities to develop health and wellness
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 179

education was no longer a viable option for BOSH. The research conducted will directly benefit
HCFR and BOSH in developing our own education, but could also serve as a potential model to
be shared with other fire service stakeholders in HCFR’s region, as well as around the U.S.
The literature review on fire service health and wellness presented several major factors
that contribute to the discussion of health and wellness education for firefighters. These factors
included major trends of what firefighters are dying from, what some of the major national level
fire service organizations have done and suggested, and what existed at a regional, state, and
local level regarding health and wellness education for firefighters. Heart attack, suicide, and
cancer are major health and wellness issues for the fire service, in much the same way that they
are an issue to the U.S. general population. Although there has been research that suggests some
impact from occupational factors of the fire service on heart attack, suicide, and cancer in
firefighters, there is also research that suggests that much of the health and wellness issues that
firefighters are suffering from are preventable through lifestyle factors such as physical activity,
nutrition, and mental activity.
The literature review documented the suggestions, standards, and models that the national
level fire service organizations have offered to the fire service as a starting point for preventive
health and wellness initiatives. Organizations like the IAFF, IAFC, NFPA, and NFFF have called
for fire service organizations to do their best to take preventive actions to reduce heart attack,
suicide, and cancer deaths where possible. However, models of what fire academy health and
wellness educational curriculum might look like were not found, and neither was data on what
initial health and wellness education currently exists within the fire service.
A sample of state fire service course catalogues were reviewed during this research. Out
of 11 state course catalogues, nine did not offer health and wellness education on preventing
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 180

heart attack, suicide, or cancer. MFRI’s course catalogue was also reviewed since they are the
state training agency that serves Maryland career and volunteer firefighters. MFRI did not offer
any health and wellness education for firefighters. Therefore, while this research was conducted
specifically for HCFR, the literature review suggests that perhaps this is a topic for national
consideration. If there are occupational links to heart attack, suicide, and cancer in firefighters,
then educating firefighters on how to prevent those issues should be considered mandatory
training. Furthermore, based on the available literature for firefighters and the U.S. general
population, consideration for preventive health and wellness education for firefighters should
include lifestyle factors. If the fire service cannot demonstrate that it is making an earnest effort
to educate on preventing heart attack, suicide, and cancer, then it cannot expect the public to
respond with legislative or financial support.
This research was conducted because HCFR and BOSH recognized a need for health and
wellness education to be developed and delivered to its firefighters starting in the academy. The
research considered whether BOSH had the knowledge, motivation, and organizational assets in
place to accomplish its goal, and if not, what would be needed to do so. Based on the literature
review of this research, preventable health and wellness issues are a growing cause of illness,
injury, and death for firefighters throughout the United States. Initial and continuing, physical
and behavioral, health and wellness education for firefighters requires local, state, and national
cooperation for development, delivery, and tracking. May this research be used as part of the
conversation for moving forward on the effort to keep firefighters safe, healthy, and well.
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 181

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APPENDIX A - Fire department call volume from 1980 to 2015
Source: National Fire Protection Association
Year Total Fires
Medical
aid
False
alarms
Mutual
aid
Hazardous
materials
Other
hazardous
conditions
Other
1980 10,819,000 2,988,000 5,045,000 896,500 274,000
1981 10,594,500 2,893,500 5,019,000 788,000 349,500
1982 10,548,000 2,538,000 5,258,000 853,500 346,500
1983 10,933,000 2,326,500 5,660,000 979,500 353,000
1984 11,070,000 2,343,000 5,735,000 972,000 413,500
1985 11,888,000 2,371,000 6,467,000 936,500 389,500
1986 11,890,000 2,271,500 6,437,500 992,500 441,000 171,500 318,000 1,258,000
1987 12,237,500 2,330,000 6,405,000 1,238,500 428,000 193,000 315,000 1,328,000
1988 13,308,000 2,436,500 7,169,500 1,404,500 490,500 204,000 333,000 1,270,000
1989 13,409,500 2,115,000 7,337,000 1,467,000 500,000 207,000 381,500 1,402,000
1990 13,707,500 2,019,000 7,650,000 1,476,000 486,500 210,000 423,000 1,443,000
1991 14,556,500 2,041,500 8,176,000 1,578,500 494,000 221,000 428,500 1,617,000
1992 14,684,500 1,964,500 8,263,000 1,598,000 514,000 220,500 400,000 1,724,500
1993 15,318,500 1,952,500 8,743,500 1,646,500 542,000 245,000 432,500 1,756,500
1994 16,127,000 2,054,500 9,189,000 1,666,000 586,500 250,000 432,500 1,948,500
1995 16,391,500 1,965,500 9,381,000 1,672,500 615,500 254,500 469,500 2,033,000
1996 17,503,000 1,975,000 9,841,500 1,816,500 688,000 285,000 536,500 2,360,500
1997 17,957,500 1,795,000 10,483,000 1,814,500 705,500 271,500 498,500 2,389,500
1998 18,753,000 1,755,500 10,936,000 1,956,000 707,500 301,000 559,000 2,538,000
1999 19,667,000 1,823,000 11,484,000 2,039,000 824,000 297,500 560,000 2,639,500
2000 20,520,000 1,708,000 12,251,000 2,126,500 864,000 319,000 543,500 2,708,000
2001 20,965,500 1,734,500 12,331,000 2,157,500 838,500 381,500 605,000 2,917,500
2002 21,303,500 1,687,500 12,903,000 2,116,000 888,500 361,000 603,500 2,744,000
2003 22,406,000 1,584,500 13,631,500 2,189,500 987,000 349,500 660,500 3,003,500
2004 22,616,500 1,550,500 14,100,000 2,106,000 984,000 354,000 671,000 2,851,000
2005 23,251,500 1,602,000 14,375,000 2,134,000 1,091,000 375,000 667,000 3,009,000
2006 24,470,000 1,642,500 15,062,500 2,119,500 1,159,500 388,500 659,000 3,438,500
2007 25,334,500 1,557,500 15,784,000 2,208,500 1,109,500 395,500 686,500 3,593,000
2008 25,252,500 1,451,500 15,767,500 2,241,500 1,214,500 394,500 697,500 3,485,500
2009 26,534,500 1,348,500 17,104,000 2,177,000 1,296,000 397,000 625,500 3,586,500
2010 28,205,000 1,331,500 18,522,000 2,187,000 1,189,500 402,000 660,000 3,913,000
2011 30,098,000 1,389,500 19,803,000 2,383,000 1,252,000 379,000 720,000 4,171,500
2012 31,854,000 1,375,000 21,705,500 2,238,000 1,326,500 360,000 694,000 4,155,000
2013 31,644,500 1,240,000 21,372,000 2,343,000 1,298,000 366,500 678,000 4,347,000
2014 31,644,500 1,298,000 20,178,000 2,488,000 1,446,500 405,000 615,000 5,214,000
2015 33,635,500 1,345,500 21,500,000 2,566,500 1,492,500 442,000 643,000 5,646,000
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 200

APPENDIX B - U.S. Firefighter Fatalities On-Duty Due to Sudden Cardiac Death 1977-2016)
Source: National Fire Protection Association
Year
Total
Deaths
Sudden
Cardiac
Deaths
Percentage
1977 157 73 46 %
1978 174 72 41
1979 126 48 38
1980 138 62 45
1981 136 72 53
1982 128 59 46
1983 113 59 52
1984 119 40 34
1985 128 52 41
1986 119 61 51
1987 132 61 46
1988 136 56 41
1989 118 63 53
1990 108 41 38
1991 108 53 49
1992 75 39 52
1993 79 40 51
1994 106 38 36
1995 98 49 50
1996 96 47 49
1997 99 41 41
1998 91 40 44
1999 113 51 45
2000 104 41 39
2001 103 41 40
2002 98 37 38
2003 106 47 44
2004 104 47 45
2005 87 39 45
2006 90 34 38
2007 106 40 38
2008 106 37 35
2009 82 35 43
2010 73 34 47
2011 61 31 51
2012 64 27 42
2013 98 29 30
2014 64 36 56
2015 68 35 51
2016 69 26 38
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 201

APPENDIX C - Health and Wellness Educational Framework References
Heart Attack
Ahn, N., & Kim, K. (2016). High-density lipoprotein cholesterol (HDL-C) in cardiovascular
disease: effect of exercise training. Integrative Medicine Research, 5(3), 212-215.
Naci, H., Salcher-Konrad, M., Dias, S., Blum, M., Sahoo, S., Nunan, D., & Ioannidis, J. (2018).
How does exercise treatment compare with antihypertensive medications? A network
meta-analysis of 391 randomised controlled trials assessing exercise and medication
effects on systolic blood pressure. Br J Sports Med, bjsports-2018.
Soteriades, E., Smith, D., Tsismenakis, A., Baur, D., & Kales, S. (2011). Cardiovascular disease
in US firefighters: a systematic review. Cardiology in Review, 19(4), 202-215.
Yang, J., Teehan, D., Farioli, A., Baur, D., Smith, D., & Kales, S. (2013). Sudden cardiac death
among firefighters ≤ 45 years of age in the United States. The American Journal of
Cardiology, 112(12), 1962-1967.
Yusuf, S., Hawken, S., Ôunpuu, S., Dans, T., Avezum, A., Lanas, F., ... & Lisheng, L. (2004).
Effect of potentially modifiable risk factors associated with myocardial infarction in 52
countries (the INTERHEART study): case-control study. The Lancet, 364(9438), 937-
952.
Cancer
Albini, A., Tosetti, F., Li, V., Noonan, D., & Li, W. (2012). Cancer prevention by targeting
angiogenesis. Nature Reviews Clinical Oncology, 9(9), 498.
Anand, P., Kunnumakara, A., Sundaram, C., Harikumar, K., Tharakan, S., Lai, O., ... &
Aggarwal, B. (2008). Cancer is a preventable disease that requires major lifestyle
changes. Pharmaceutical Research, 25(9), 2097-2116.
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 202

Calle, E., & Kaaks, R. (2004). Overweight, obesity and cancer: epidemiological evidence and
proposed mechanisms. Nature Reviews Cancer, 4(8), 579.
Calle, E., & Thun, M. (2004). Obesity and cancer. Oncogene, 23(38), 6365.
Carroll, K. (1998). Obesity as a risk factor for certain types of cancer. Lipids, 33(11), 1055-1059.
Pothiwala, P., Jain, S., & Yaturu, S. (2009). Metabolic syndrome and cancer. Metabolic
Syndrome and Related Disorders, 7(4), 279-288.
Russo, A., Autelitano, M., & Bisanti, L. (2008). Metabolic syndrome and cancer risk. European
Journal of Cancer, 44(2), 293-297.
Seyfried, T. (2015). Cancer as a mitochondrial metabolic disease. Frontiers in Cell and
Developmental Biology, 3, 43.
Williams, S. (2013). Link between obesity and cancer. Proceedings of the National Academy of
Sciences, 110(22), 8753-8754.
Wolin, K., Carson, K., & Colditz, G. (2010). Obesity and cancer. The oncologist, 15(6), 556-565.
Suicide
Davidson, C., Babson, K., Bonn ‐Miller, M., Souter, T., & Vannoy, S. (2013). The impact of
exercise on suicide risk: examining pathways through depression, PTSD, and sleep in an
inpatient sample of veterans. Suicide and Life ‐Threatening Behavior, 43(3), 279-289.
Davidson, C., Wingate, L., Grant, D., Judah, M., & Mills, A. (2011). Interpersonal suicide risk
and ideation: The influence of depression and social anxiety. Journal of Social and
Clinical Psychology, 30(8), 842-855.
James, A., Lai, F., & Dahl, C. (2004). Attention deficit hyperactivity disorder and suicide: a
review of possible associations. Acta Psychiatrica Scandinavica, 110(6), 408-415.
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 203

Steele, I., Thrower, N., Noroian, P., & Saleh, F. (2018). Understanding suicide across the
lifespan: A United States perspective of suicide risk factors, assessment &
management. Journal of Forensic Sciences, 63(1), 162-171.
Stickley, A., Koyanagi, A., Ruchkin, V., & Kamio, Y. (2016). Attention-deficit/hyperactivity
disorder symptoms and suicide ideation and attempts: Findings from the Adult
Psychiatric Morbidity Survey 2007. Journal of Affective Disorders, 189, 321-328.
Taylor, P., Gooding, P., Wood, A., & Tarrier, N. (2011). The role of defeat and entrapment in
depression, anxiety, and suicide. Psychological Bulletin, 137(3), 391.
Voss, W., Kaufman, E., O'Connor, S., Comtois, K., Conner, K., & Ries, R. (2013). Preventing
addiction related suicide: A pilot study. Journal of Substance Abuse Treatment, 44(5),
565-569.
Yuodelis ‐Flores, C., & Ries, R. (2015). Addiction and suicide: a review. The American Journal
on Addictions, 24(2), 98-104.
Physical Activity
Bonnet, F., Irving, K., Terra, J., Nony, P., Berthezène, F., & Moulin, P. (2005). Anxiety and
depression are associated with unhealthy lifestyle in patients at risk of cardiovascular
disease. Atherosclerosis, 178(2), 339-344.
Carli, V., Hoven, C., Wasserman, C., Chiesa, F., Guffanti, G., Sarchiapone, M., ... & Cosman, D.
(2014). A newly identified group of adolescents at “invisible” risk for psychopathology
and suicidal behavior: findings from the SEYLE study. World Psychiatry, 13(1), 78-86.
Celis ‐Morales, C., Marsaux, C., Livingstone, K., Navas ‐Carretero, S., San ‐Cristobal, R.,
O'donovan, C., ... & Kolossa, S. (2016). Physical activity attenuates the effect of the FTO
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 204

genotype on obesity traits in European adults: the Food4Me study. Obesity, 24(4), 962-
969.
Bouchard, C., Depres, J. P., & Tremblay, A. (1993). Exercise and obesity. Obesity
Research, 1(2), 133-147.
Colberg, S., Sigal, R., Fernhall, B., Regensteiner, J., Blissmer, B., Rubin, R., ... & Braun, B.
(2010). Exercise and type 2 diabetes: the American College of Sports Medicine and the
American Diabetes Association: joint position statement executive summary. Diabetes
Care, 33(12), 2692-2696.
Edwards, M., & Loprinzi, P. (2016). Experimentally increasing sedentary behavior results in
increased anxiety in an active young adult population. Journal of Affective
Disorders, 204, 166-173.
Endrighi, R., Steptoe, A., & Hamer, M. (2016). The effect of experimentally induced
sedentariness on mood and psychobiological responses to mental stress. The British
Journal of Psychiatry, 208(3), 245-251.
Eriksson, J., Taimela, S., & Koivisto, V. (1997). Exercise and the metabolic
syndrome. Diabetologia, 40(2), 125-135.
Fetzner, M., & Asmundson, G. (2015). Aerobic exercise reduces symptoms of posttraumatic
stress disorder: A randomized controlled trial. Cognitive Behaviour Therapy, 44(4), 301-
313.
Halperin, J. (2015). Joggin’for your noggin: the role of physical activity in attention-
deficit/hyperactivity disorder. Journal of the American Academy of Child & Adolescent
Psychiatry, 54(7), 537-538.
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 205

Leaf, D. A. (2003). The effect of physical exercise on reverse cholesterol
transport. Metabolism, 52(8), 950-957.
Leggio, M., Fusco, A., Limongelli, G., & Sgorbini, L. (2018). Exercise training in patients with
pulmonary and systemic hypertension: A unique therapy for two different
diseases. European Journal of Internal Medicine, 47, 17-24.
Lynch, W., Peterson, A., Sanchez, V., Abel, J., & Smith, M. (2013). Exercise as a novel
treatment for drug addiction: a neurobiological and stage-dependent
hypothesis. Neuroscience & Biobehavioral Reviews, 37(8), 1622-1644.
Miyazaki, H., Oh-ishi, S., Ookawara, T., Kizaki, T., Toshinai, K., Ha, S., ... & Ohno, H. (2001).
Strenuous endurance training in humans reduces oxidative stress following exhausting
exercise. European Journal of Applied Physiology, 84(1-2), 1-6.
Naci, H., Salcher-Konrad, M., Dias, S., Blum, M., Sahoo, S., Nunan, D., & Ioannidis, J. (2018).
How does exercise treatment compare with antihypertensive medications? A network
meta-analysis of 391 randomised controlled trials assessing exercise and medication
effects on systolic blood pressure. Br J Sports Med, bjsports-2018.
Salmon, P. (2001). Effects of physical exercise on anxiety, depression, and sensitivity to stress: a
unifying theory. Clinical Psychology Review, 21(1), 33-61.
Seyfried, T., Flores, R., Poff, A., & D’agostino, D. (2013). Cancer as a metabolic disease:
implications for novel therapeutics. Carcinogenesis, 35(3), 515-527.
Teychenne, M., Ball, K., & Salmon, J. (2010). Sedentary behavior and depression among adults:
a review. International Journal of Behavioral Medicine, 17(4), 246-254.
Thompson, P. (2003). Exercise and physical activity in the prevention and treatment of
atherosclerotic cardiovascular disease.
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 206

Nutrition
American Diabetes Association. (2002). Evidence-based nutrition principles and
recommendations for the treatment and prevention of diabetes and related
complications. Diabetes Care, 25(1), 202-212.
Avena, N., Rada, P., & Hoebel, B. (2008). Evidence for sugar addiction: behavioral and
neurochemical effects of intermittent, excessive sugar intake. Neuroscience &
Biobehavioral Reviews, 32(1), 20-39.
Ayala-Peña, S., & Torres-Ramos, C. (2014). Oxidative Stress, Aging and Mitochondrial
Dysfunction in Liver Pathology. In Aging (pp. 39-48).
Bodnar, L., & Wisner, K. (2005). Nutrition and depression: implications for improving mental
health among childbearing-aged women. Biological Psychiatry, 58(9), 679-685.
Carter, C., Urbanowicz, M., Hemsley, R., Mantilla, L., Strobel, S., Graham, P., & Taylor, E.
(1993). Effects of a few food diet in attention deficit disorder. Archives of Disease in
Childhood, 69(5), 564-568.
Deed, G., Barlow, J., Kawol, D., Kilov, G., Sharma, A., & Yu Hwa, L. (2015). Diet and
diabetes. Australian Family Physician, 44(5), 288.
Dobson, M., Choi, B., Schnall, P. L., Wigger, E., Garcia ‐Rivas, J., Israel, L., & Baker, D. (2013).
Exploring occupational and health behavioral causes of firefighter obesity: a qualitative
study. American Journal of Industrial Medicine, 56(7), 776-790.
Garaulet, M., & Madrid, J. (2010). Chronobiological aspects of nutrition, metabolic syndrome
and obesity. Advanced Drug Delivery Reviews, 62(9-10), 967-978.
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Goff, L., Cowland, D., Hooper, L., & Frost, G. (2013). Low glycaemic index diets and blood
lipids: a systematic review and meta-analysis of randomised controlled trials. Nutrition,
Metabolism and Cardiovascular Diseases, 23(1), 1-10.
Frost, G., Leeds, A., Dore, C., Madeiros, S., Brading, S., & Dornhorst, A. (1999). Glycaemic
index as a determinant of serum HDL-cholesterol concentration. The Lancet, 353(9158),
1045-1048.
Harman, D. (1962). Role of free radicals in mutation, cancer, aging, and the maintenance of
life. Radiation Research, 16(5), 753-763.
Jacka, F., Pasco, J., Mykletun, A., Williams, L., Hodge, A., O'reilly, S., ... & Berk, M. (2010).
Association of Western and traditional diets with depression and anxiety in
women. American Journal of Psychiatry, 167(3), 305-311.
Li, W., Li, V., Hutnik, M., & Chiou, A. (2012). Tumor angiogenesis as a target for dietary cancer
prevention. Journal of Oncology, 2012.
Maruyama, K., & Iso, H. (2014). Overview of the Role of Antioxidant Vitamins as Protection
Against Cardiovascular Disease: Implications for Aging. In Aging (pp. 213-224).
Mekha, M., Shobha, R., Rajeshwari, C., & Andallu, B. (2014). Aging and Arthritis: Oxidative
Stress and Antioxidant Effects of Herbs and Spices. In Aging (pp. 233-245).
Modena, M. (2014). Hypertension, menopause and natural antioxidants in foods and the diet.
In Aging (pp. 225-231).
Mohamed, S. (2014). Herbs and Spices in Aging. In Aging (pp. 99-107).
Morrison, C., & Berthoud, H. (2007). Neurobiology of nutrition and obesity. Nutrition
Reviews, 65(12), 517-534.
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Raju, M. (2017). Medical nutrition in mental health and disorders. Indian Journal of
Psychiatry, 59(2), 143.
Rodriguez-Iturbe, B., Zhan, C. D., Quiroz, Y., Sindhu, R., & Vaziri, N. (2003). Antioxidant-rich
diet relieves hypertension and reduces renal immune infiltration in spontaneously
hypertensive rats. Hypertension, 41(2), 341-346.
Sarkar, D., & Shetty, K. (2014). Diabetes as a Disease of Aging, and the Role of Oxidative
Stress. In Aging (pp. 61-69).
Sarris, J., Logan, A., Akbaraly, T., Amminger, G., Balanzá-Martínez, V., Freeman, M., ... &
Nanri, A. (2015). Nutritional medicine as mainstream in psychiatry. The Lancet
Psychiatry, 2(3), 271-274.
Skulachev, V., Isaev, N., Kapay, N., Popova, O., Stelmashook, E., Lyamzaev, K., ... &
Skrebitsky, V. (2014). Mitochondria-targeted antioxidants and alzheimer’s disease.
In Aging (pp. 195-201).
Sies, H., Stahl, W., & Sevanian, A. (2005). Nutritional, dietary and postprandial oxidative
stress. The Journal of Nutrition, 135(5), 969-972.
Smith, R., Porteous, C., Coulter, C., & Murphy, M. (1999). Selective targeting of an antioxidant
to mitochondria. European Journal of Biochemistry, 263(3), 709-716.
Toblin, R., Adrian, A., Hoge, C., & Adler, A. (2018). Energy Drink Use in US Service Members
After Deployment: Associations With Mental Health Problems, Aggression, and
Fatigue. Military Medicine, 183(11-12), e364-e370.
Wachtel-Galor, S., Siu, P., & Benzie, I. (2014). Antioxidants, vegetarian diets and aging.
In Aging (pp. 81-91).
Mental Activity
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Boehm, J., & Kubzansky, L. (2012). The heart's content: the association between positive
psychological well-being and cardiovascular health. Psychological Bulletin, 138(4), 655.
Eagleson, C., Hayes, S., Mathews, A., Perman, G., & Hirsch, C. (2016). The power of positive
thinking: Pathological worry is reduced by thought replacement in Generalized Anxiety
Disorder. Behaviour Research and Therapy, 78, 13-18.
Kubzansky, L., Boehm, J., & Segerstrom, S. (2015). Positive psychological functioning and the
biology of health. Social and Personality Psychology Compass, 9(12), 645-660.
McCanlies, E., Mnatsakanova, A., Andrew, M., Burchfiel, C., & Violanti, J. (2014). Positive
psychological factors are associated with lower PTSD symptoms among police officers:
post Hurricane Katrina. Stress and Health, 30(5), 405-415.
Smith, B., Ortiz, J., Steffen, L., Tooley, E., Wiggins, K., Yeater, E., ... & Bernard, M. (2011).
Mindfulness is associated with fewer PTSD symptoms, depressive symptoms, physical
symptoms, and alcohol problems in urban firefighters. Journal of Consulting and Clinical
Psychology, 79(5), 613.
Wagner, S., & Martin, C. (2012). Can Firefighters’ Mental Health Be Predicted by Emotional
Intelligence and Proactive Coping?. Journal of Loss and Trauma, 17(1), 56-72.

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APPENDIX D - Interview Protocol
Respondent (Name): _______________________________________________
Location of Interview: ____________________________________________________
Time in / Time Out: _________________________________________
Introduction
Thank you for meeting with me today. I am conducting this interview as part of my dissertation
research with my doctoral program at University of Southern California. I am seeking your
insight and experiences to better understand the state of physical and behavioral health and
wellness education in HCFR, as well as ideas that may help to improve this type of education. I
anticipate taking no more than 45 minutes of your time, and I have 19 questions for your
consideration.
Your participation is completely voluntary. We can skip any question you want at any time, and
you may stop the interview at any time. Any identifiable information obtained in connection with
this study will remain confidential. Your responses will be coded with a false name (pseudonym)
and maintained separately from your answers.
If you are comfortable with it, I would like to record our conversation and the recording will be
destroyed after it is transcribed. Are you comfortable if I record the conversation?
Do you have any questions?
1. What are the top three health risks that are the most critical for firefighters currently?
If warranted, follow up:
A. What are some ways to prevent the health risks that you mentioned?
B. What cultural aspects of the fire service are leading to these health risks?
2. How would you describe the culture of prevention in HCFR? Why?
3. What suggestions would you make to improve BOSH members’ knowledge on firefighter
health risks and prevention of those risks?
4. What processes are needed for effective education?
If warranted, follow up:
A. What are some qualities of an effective instructor?
5. How would you describe the culture of education in general in HCFR? Why?
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 211

6. What suggestions would you make to improve BOSH members’ instructional knowledge
and effectiveness? Why?
7. What role does initial and continuing education play in regards to health and wellness for
firefighters?
Follow up:
A. What role does initial and continuing education play in regards to firefighter
behavioral change?
8. Tell me about the current status of initial and continuing health and wellness education in
HCFR.
9. What suggestions would you make on how to improve initial and continuing health and
wellness education in HCFR? Why?
10. What is BOSH’s role in firefighter health and wellness?
Follow up:
A. What factors are needed for positive change in one’s lifestyle?
11. How would you describe HCFR’s view of BOSH? Why?
12. What changes, if any, would you make regarding the way HCFR uses BOSH for
firefighter health and wellness?
13. What authority does BOSH have regarding initial or continuing health and wellness
education?
Follow up:
A. What factors contribute to BOSH’s authority, or lack of authority regarding health
and wellness education?
14. What changes would you make, if any, with regards to BOSH’s authority on health and
wellness education?
15. How would you describe the resource allocation to BOSH from HCFR?
Follow up:
A. What factors contribute to the determination of BOSH’s resource allocation?
16. How would you change resource allocation for BOSH?
17. How would you describe the Fire Chief’s commitment to health and wellness?
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 212

18. How would you assess the commitment of BOSH members toward health and wellness?
Follow up:
A. What is your experience of HCFR’s support of BOSH to cultivate homegrown
health and wellness champions?
19. What are some ways to improve the commitment of the Fire Chief and BOSH members
toward health and wellness?
Closing Question
Is there anything else you would like to add before we end our conversation?
Closing, Thank You, Follow Up
Thank you again for sharing your thoughts with me today. I really appreciate your
willingness to participate in my study and support my research. Would you mind a follow up
email if I have any additional questions? Thank you again for your participation.

HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 213

APPENDIX E - Survey Items
Survey Instructions
The purpose of this survey is to assess how well BOSH and HCFR are doing in the
mission to provide firefighters with physical and behavioral health and wellness education. As a
BOSH member, you are being asked to provide your opinion on the following 14 questions.
Please mark one answer for each question to indicate how strongly you either agree or disagree
with each survey item. If you have any questions regarding the survey items, please feel free to
contact the researcher.
1. BOSH has provided me enough education on physical health and wellness to develop a
comprehensive curriculum on firefighter physical health and wellness.
A. Strongly agree
B. Somewhat agree
C. Somewhat disagree
D. Strongly disagree
E. N/A
2. BOSH has provided me enough education on behavioral health and wellness to develop
a comprehensive curriculum on firefighter behavioral health and wellness.
A. Strongly agree
B. Somewhat agree
C. Somewhat disagree
D. Strongly disagree
E. N/A
3. BOSH has provided me enough education on curriculum development to properly
develop a comprehensive curriculum.
A. Strongly agree
B. Somewhat agree
C. Somewhat disagree
D. Strongly disagree
4. BOSH has provided me enough education on classroom instruction to properly deliver a
comprehensive firefighter health and wellness curriculum.
A. Strongly agree
B. Somewhat agree
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 214

C. Somewhat disagree
D. Strongly disagree
5. Educating firefighters about physical and behavioral health and wellness in the academy
should be a priority for HCFR.
A. Strongly agree
B. Somewhat agree
C. Somewhat disagree
D. Strongly disagree
6. On a scale of 1-10 (10 being most important), how important do you feel it is to educate
firefighters about physical and behavioral health and wellness in the academy?
1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
7. Educating firefighters about physical and behavioral health and wellness throughout
their careers should be a priority for HCFR.
A. Strongly agree
B. Somewhat agree
C. Somewhat disagree
D. Strongly disagree
8. On a scale of 1-10 (10 being most important), how important do you feel it is to educate
firefighters about physical and behavioral health and wellness throughout their careers?
1. 2. 3. 4. 5. 6. 7. 8. 9. 10.
9. Education can change firefighters’ lifestyles and habits.
A. Strongly agree
B. Somewhat agree
C. Somewhat disagree
D. Strongly disagree
10. BOSH is capable of improving HCFR firefighters’ health and wellness through
education.
A. Strongly agree
B. Somewhat agree
C. Somewhat disagree
D. Strongly disagree
11. BOSH should have the authority to mandate physical and behavioral health and wellness
education throughout all stages of a firefighter’s career.
A. Strongly agree
B. Somewhat agree
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 215

C. Somewhat disagree
D. Strongly disagree
12. BOSH receives enough resources to educate firefighters on health and wellness
throughout all stages of their career.
A. Strongly agree
B. Somewhat agree
C. Somewhat disagree
D. Strongly disagree
13. The Fire Chief is fully committed to health and wellness education.
B. Strongly agree
C. Somewhat agree
D. Somewhat disagree
E. Strongly disagree
14. BOSH has at least one member that is fully committed to health and wellness education.
A. Strongly agree
B. Somewhat agree
C. Somewhat disagree
D. Strongly disagree

HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 216

APPENDIX F - Survey Items, Mean, and Standard Deviation
Below is a matrix showing a total of 46 respondents for 14 items. One respondent did not
answer Item 13. All Items except Item 6 and Item 8 were Likert-type items and were converted
as follows: Strongly Agree = 1, Agree = 2, Disagree = 3, and Strongly Disagree = 4. Item 6 and
Item 8 were asked the respondent to provide a value on a 1-10 scale.
Items
Strongly Agree (1) Agree (2) Disagree (3) Strongly Disagree (4)
Mean
Standard
Deviation
BOSH has provided me enough education on physical health and
wellness to develop a comprehensive curriculum on firefighter
physical health and wellness.
2.47 0.74
BOSH has provided me enough education on behavioral health and
wellness to develop a comprehensive curriculum on firefighter
behavioral health and wellness.
2.45 0.76
BOSH has provided me enough education on curriculum
development to properly develop a comprehensive curriculum.
2.83 0.82
BOSH has provided me enough education on classroom instruction
to properly deliver a comprehensive firefighter health and wellness
curriculum.
2.87 0.78
Educating firefighters about physical and behavioral health and
wellness in the academy should be a priority for HCFR.
1.30 0.59
On a scale of 1-10 (10 being most important), how important do you
feel it is to educate firefighters about physical and behavioral health
and wellness in the academy?
9.52 1.01
Educating firefighters about physical and behavioral health and
wellness throughout their careers should be a priority for HCFR.
1.22 0.42
On a scale of 1-10 (10 being most important), how important do you
feel it is to educate firefighters about physical and behavioral health
and wellness throughout their careers?
9.43 1.00
Education can change firefighters’ lifestyles and habits. 1.52 0.55
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 217

BOSH is capable of improving HCFR firefighters’ health and
wellness through education.
1.63 0.61
BOSH should have the authority to mandate physical and behavioral
health and wellness education throughout all stages of a firefighter’s
career.
1.91 0.89
BOSH receives enough resources to educate firefighters on health
and wellness throughout all stages of their career.
2.87 0.72
The Fire Chief is fully committed to health and wellness education. 2.29 0.79
BOSH has at least one member that is fully committed to health and
wellness education.
1.30 0.63
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 218

APPENDIX G - Health and Wellness BOSH Stakeholder Post-Training Evaluation
Instructions:
- For the following questions, please use the following scale:
0 = strongly disagree- 10 = strongly agree
- Please circle the appropriate rating to indicate the degree to which you agree with each
statement.

Rating Item
Strongly disagree Strongly Agree
0 1 2 3 4 5 6 7 8 9 10
1. I know the top three health issues for firefighters.
Please list:
________________________________________________
________________________________________________
________________________________________________

2. I know the three major lifestyle factors that are related
to the top three health issues.
Please list:
________________________________________________
________________________________________________
________________________________________________

3. I know the three main components of pedagogy.
Please list:
________________________________________________
________________________________________________
________________________________________________

4. I know the three main factors of being an effective
instructor.
Please list:
________________________________________________
________________________________________________
________________________________________________

5. I can design an educational module that includes the
necessary components of pedagogy.
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 219

Please list:
________________________________________________
________________________________________________
________________________________________________

6. The work I am doing as a PFT/PST makes a difference
in the health and wellness of my coworkers.
Please list:
________________________________________________
________________________________________________
________________________________________________

7. I believe I can educate my peers on health and wellness
issues in person.
Please list:
________________________________________________
________________________________________________
________________________________________________

8. I will conduct educational interactions with firefighters
on health and wellness issues.
Please list:
________________________________________________
________________________________________________
________________________________________________

9. I felt mentally stimulated by the material that was
presented on health and wellness.
Please list:
________________________________________________
________________________________________________
________________________________________________

10. I felt mentally stimulated by the material that was
presented on educational processes.
Please list:
________________________________________________
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 220

________________________________________________
________________________________________________

11. What I learned from the training is useful for me as a
PFT/PST.
Please list:
________________________________________________
________________________________________________
________________________________________________

12. I will recommend this training to other PFTs/PSTs.
Please list:
________________________________________________
________________________________________________
________________________________________________

HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 221

APPENDIX H - Health and Wellness BOSH Stakeholder 3 Month Follow-Up Evaluation
Instructions:
- For the following questions, please use the following scale:
0 = strongly disagree- 10 = strongly agree
- Please circle the appropriate rating to indicate the degree to which you agree with each
statement.

Rating Item
Strongly disagree Strongly Agree
0 1 2 3 4 5 6 7 8 9 10
1. The training improved my ability to understand the
educational process.
Strongly disagree Strongly Agree
0 1 2 3 4 5 6 7 8 9 10
2. The training improved my ability to understand the
educational process.

3. I am able to deliver health and wellness education to my
peers more clearly after the training.
a. I conducted ____ interactions last month.

4. I use the job aids every time I educate on health and
wellness.
Which job aid(s) do you use the most? Please list:
________________________________________________
________________________________________________
________________________________________________

5. I research more health and wellness information now
than I did before.
b. I have created _________ products.
c. I have created _________ modules.

6. What would help you to develop more health and
wellness products or modules?
Please list:
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 222

APPENDIX I - Health and Wellness Data Analysis (Level 3)

Figure 20. Health and Wellness Education Tracking (Level 3).

Figure 21. Stakeholder Goal- 16 hours of Physical and Behavioral Health and Wellness
Education.

HEALTH AND WELLNESS EDUCATION IN THE FIRE SERVICE 223

APPENDIX J - Recruitment Letter
Dear _______________________________ :
My name is Gamaliel Baer, and I am a doctoral candidate in the Rossier School of Education at
University of Southern California. I am conducting a research study as part of my dissertation,
examining physical and behavioral health and wellness education. The research has been
approved by HCFR.
You are cordially invited to participate in the study.
If you agree, you are invited to:
- Complete an anonymous online survey of questions that is anticipated to take no more
than 10 minutes to complete.
- Participate in an in-person interview. The interview is voluntary and anticipated to last
approximately 45 minutes. You may choose to skip any questions that you do not want to
answer; if you prefer the interview not be recorded, handwritten notes will be taken.
Participation in this study is completely voluntary. Your identity as a participant will
remain confidential at all times during and after the study.
If you would like to participate in the survey, please begin the survey via the link.
If you would like to participate in the in-person interview, please email or call me at the contact
information below.
If you have any questions, please feel free to contact me at gbaer@usc.edu or 443-878-8685.
Thank you in advance for your participation.
Gamaliel Baer
Doctoral Candidate - Rossier School of Education
University of Southern California

Abstract (if available)

Abstract Firefighters are dying more from health and wellness issues than from fires. Heart attack accounts for roughly 50% of on-duty deaths. Off-duty deaths from cancer and suicide far outnumber heart attack deaths. These three health and wellness issues have been a focus of fire service research as potential job-related issues. However, like the U.S. general population, these three health and wellness issues are highly preventable if the lifestyle risk factors involved are addressed early. This research was conducted for Howard County Fire and Rescue (HCFR) in Howard County, Maryland. HCFR has roughly 500 career firefighters and roughly 500 volunteer firefighters. It is in central Maryland and serves over 320,000 citizens. HCFR firefighters did not have access to initial or continuing health and wellness education. The overarching focus of this research was to understand what knowledge, motivation, and organizational factors were needed to develop a health and wellness educational curriculum, and what the solutions to those needs might be. The participants of this study included 47 members of the Bureau of Occupational Safety and Health, which included field and headquarters personnel. A mixed methods research study included document analysis, surveys, and interviews. While HCFR had knowledge, motivation, and organizational assets, development was needed in knowledge and organizational factors for a health and wellness educational curriculum to be developed and delivered. National consideration should be given to record and disseminate what initial and continuing health and wellness education is available to firefighters either from the state training agency, or the fire department.

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Asset Metadata

Creator Baer, Gamaliel David (author)

Core Title Initial and continuing physical and behavioral health and wellness education in the fire service: an innovation study on heart attack, suicide, and cancer prevention for Howard County Fire and Rescue

School Rossier School of Education

Degree Doctor of Education

Degree Program Organizational Change and Leadership (On Line)

Publication Date 04/17/2019

Defense Date 03/20/2019

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag behavioral,cancer,education,firefighter,health,heart attack,OAI-PMH Harvest,physical,Suicide,wellness

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Seli, Helena (committee chair), Canny, Eric (committee member), Datta, Monique (committee member), Dreisbach, Christopher (committee member), Harnett, Christina (committee member)

Creator Email fd8148@howardcountymd.gov,gdbaer@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-138621

Unique identifier UC11676696

Identifier etd-BaerGamali-7201.pdf (filename),usctheses-c89-138621 (legacy record id)

Legacy Identifier etd-BaerGamali-7201.pdf

Dmrecord 138621

Document Type Dissertation

Format application/pdf (imt)

Rights Baer, Gamaliel David

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA