Work-related factors in the etiology of symptoms of post-traumatic stress among first responders: the <i>Brazilian Firefighters Longitudinal Health Study</i> (FLoHS)

Vasconcelos, Alina Gomide; Lima, Eduardo de Paula; Teoh, Kevin; do Nascimento, Elizabeth; MacLennan, Sara; Cox, Tom

doi:10.1590/0102-311X00135920

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ARTICLE • Cad. Saúde Pública 37 (9) • 2021 • https://doi.org/10.1590/0102-311X00135920 copy

Work-related factors in the etiology of symptoms of post-traumatic stress among first responders: the Brazilian Firefighters Longitudinal Health Study (FLoHS)

Fatores relacionados ao trabalho na etiologia de sintomas de estresse pós-traumático entre socorristas: o Estudo Longitudinal de Saúde em Bombeiros Brasileiros (FLoHS)

Factores laborales relacionados con la etiología de síntomas de estrés postraumático entre trabajadores de primeros auxilios: el Estudio Longitudinal de Salud en Bomberos Brasileños (FLoHS)

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract:

Two important aspects must be accounted for when discussing the mental health of first responders and, in particular, their report of post-traumatic stress symptoms (PTSS). The first concerns the provision of quantitative data from longitudinal study designs, the second concerns the sophistication of the work-related model used to frame such studies. This is a report on the development of a model for Brazilian firefighters who also work as first responders, from the establishment of a longitudinal panel design study, the Brazilian Firefighter Longitudinal Health Study (FLoHS). The first objective was to compare trainee and active firefighters based on their follow-up data with a nationwide sample of similarly aged Brazilians. The second was to test the effect that operational and organizational experiences had on firefighters’ PTSS level during follow up. At baseline, trainee firefighters came from higher socioeconomic backgrounds, were healthier and less exposed to trauma compared to a similarly aged national sample. At follow up, they reported higher prevalence of smoking, sleep problems, anhedonia and were more likely to be overweight. PTSS was predicted by operational and organizational stressors, even when controlled for health status at baseline. The results present not only the differences in the predictive status of operational and organizational events in relation to PTSS, but also how the effects of such events might interact. The data suggest the need for evidence-based interventions, support provided and changes at work environments to improve report rates for mental health in general and for PTSS in particular.

Keywords:
Post-Traumatic Stress Disorders; Firefighters; Longitudinal Studies; Occupational Exposure

Variables	Baseline	Follow up	Type
1. Sociodemographic
Sex, race, age, marital status, schooling, income	Yes	Yes	Exposure
Mother’s schooling	Yes	No	Exposure
2. Psychological characteristics
Personality	Yes	No	Exposure
Cognitive beliefs	Yes	Yes	Exposure
Coping with occupational related-traumatic events	No	Yes	Exposure and outcome
3. Mental health symptoms
Symptoms of anxiety	Yes	No	Exposure
Symptoms of depression	Yes	Yes	Outcome
Symptoms of CMD	Yes	Yes	Outcome
Symptoms of PTS	Yes	Yes	Outcome
4. Other mental health outcomes
Previous diagnostic of mental disorder (self-report)	Yes	Yes	Exposure and outcome
Psychiatric medication use	Yes	Yes	Exposure and outcome
Sleep problems	Yes	Yes	Outcome
5. Nocive behavior
Alcohol abuse	Yes	Yes	Exposure and outcome
Tobacco use	Yes	Yes	Exposure and outcome
Physical activity	No	Yes	Exposure
6. Sickness absence
Number of sick-leave episodes, number of days of sickness absence	Yes	Yes	Exposure and outcome
7. Physical health status
Diagnosis of chronic non-communicable diseases	Yes	Yes	Exposure
Weight and height	Yes	Yes	Exposure
8. Stressful and traumatic events
Exposure to stressful life events unrelated to death or risk of death	Yes	Yes	Exposure
Exposure to traumatic life events	Yes	No	Exposure
Organizational stressors	No	Yes	Exposure
Operational stressors	No	Yes	Exposure

Sociodemographic information	2014 Cohort baseline		2017 Cohort baseline		2014 Cohort follow up		Brazilian adults
Sociodemographic information	%	95%CI	%	95%CI	%	95%CI	%	95%CI
Sex ^,^,**
Man	90.1	87.6; 92.5	89.0	86.3; 91.8	88.5	84.9; 92.0	47.8	46.3; 49.4
Woman	9.9	7.5; 12.4	11.0	8.2; 13.7	11.5	7.9; 15.1	52.2	50.6; 53.7
Race ^,^,**^,#
White	40.5	36.5; 44.5	44.4	40.0; 48.8	44.6	39.0; 50.1	43.5	42.2; 45.0
Mixed	46.2	42.1; 50.3	45.4	41.0; 49.8	39.4	33.9; 44.9	46.6	45.2; 48.0
Black	10.5	8.0; 13.0	9.5	6.9; 12.1	10.3	6.9; 13.6	8.5	7.8; 9.3
Other	2.8	1.4; 4.1	0.6	0.1; 1.3	5.8	3.2; 8.4	1.4	1.1; 1.8
Age (years) ^,^,**^,#,##
Mean (SD)	23.6	(3.53)	24.3	(3.05)	27.7	(3.52)	24.0	(0.05)
< 21	22.2	18.8; 25.6	14.2	11.1; 17.3	0.0		26.5	25.1; 27.9
21-23	28.6	24.9; 32.3	25.4	21.5; 29.2	11.9	8.3; 15.5	23.9	22.6; 25.2
24-26	25.7	22.1; 29.2	31.2	27.1; 35.3	28.8	23.8; 33.9	24.9	23.7; 26.2
> 26	23.6	20.1; 27.0	29.2	25.2; 33.2	59.3	53.8; 64.8	24.7	23.6; 25.9
Marital status ^,^,**^,##
Living with a partner	15.3	12.3; 18.3	15.7	12.5; 19.0	39.4	33.9; 44.9	18.6	17.5; 19.7
Living alone	84.7	8.2; 8.8	84.3	81.0; 87.5	60.6	55.1; 66.0	81.4	80.3; 82.4
Schooling ^,^,**^,##
Elementary or less	0.0		0.0		0.0		38.7	37.2; 40.2
High school	38.3	34.3; 42.3	17.1	13.7; 20.4	34.0	28.8; 39.4	37.8	36.4; 39.3
Some college	39.7	35.7; 43.8	47.6	43.1; 52.0	38.1	32.8; 43.7	14.8	13.8; 15.9
Higher education	22.0	18.6; 25.4	35.4	31.1; 39.6	27.6	22.7; 32.6	8.7	7.8; 9.6
Mother’s schooling ^#
Elementary school	39.2	34.9; 43.5	24.1	20.3; 27.9	-		-
High school	36.4	32.2; 40.7	34.5	30.3; 38.7
College	24.3	20.6; 28.1	41.4	37.1; 45.8
Income (minimum wages per family member) ^,*^,#
< 1	30.8	26.7; 34.9	21.6	17.9; 25.5	-		90.4	89.6; 91.1
1-1.9	37.2	32.9; 41.5	44.1	39.7; 48.6			6.5	5.9; 7.2
2-2.9	21.4	17.8; 25.0	15.0	11.8; 18.2			1.7	1.4; 2.0
> 3	10.6	7.9; 13.3	19.3	15.8; 22.8			1.4	1.2; 1.7

Health information	2014 Cohort baseline		2017 Cohort baseline		2014 Cohort follow up		Brazilian adults
Health information	%	95%CI	%	95%CI	%	95%CI	%	95%CI
Chronic non-communicable diseases ^,*
No	85.7	82.8; 88.6	80.9	77.5; 84.4	-		80.7	79.5; 81.9
Yes	14.3	11.4; 17.2	19.1	15.6; 22.5			19.3	18.1; 20.5
BMI (kg/m²) ^,*^,#,##
Normal (< 25)	76.5	73.0; 80.0	71.9	67.9; 75.9	55.5	49.8; 61.1	62.5	60.7; 64.3
Overweigh (> 25)	23.5	20.0; 27.0	28.1	24.1; 32.1	44.5	38.9; 50.2	37.5	35.7; 39.3
Smoking ^,^,**^,#,##
Non-smoker	87.5	84.3; 89.8	92.4	90.0; 94.7	89.4	86.0; 92.9	88.8	87.8; 89.7
Ex-smoker	10.4	7.8; 12.8	6.0	3.9; 8.1	6.4	3.7; 9.1	2.4	2.0; 2.9
Smoker	2.1	0.9; 3.3	1.7	0.5; 2.8	4.2	1.9; 6.4	8.8	7.9; 9.8
Previous diagnose of mental health (in life) **^,#
No	98.1	96.7; 99.1	96.9	95.4; 98.5	-		95.7	95.0; 96.3
Yes	1.9	0.7; 3.0	3.1	1.5; 4.6			4.3	3.7; 5.0
CMD disorder symptoms ***
No	96.5	95.0; 98.0	96.6	94.9; 98.1	87.1	83.4; 90.9	-
Yes	3.5	2.0; 5.0	3.4	1.8; 5.1	12.9	9.1; 16.6
Anxiety symptoms
No	98.0	93.7; 97.2	98.5	97.5; 99.6	-		-
Yes	2.0	0.7; 3.0	1.5	0.4; 2.5
Depression symptoms **^,#
No	98.7	97.7; 99.7	98.9	97.9; 99.8	-		94.2	93.5; 94.8
Yes	1.3	0.3; 2.3	1.1	0.1; 2.0			5.8	5.2; 6.5
PTSS ^,**
No	98.3	97.1; 99.3	99.8	97.5; 99.6	94.6	92.0; 97.1	-
Yes	1.6	0.5; 2.6	0.2	0.0; 0.6	5.4	2.9; 8.0
Sleep problems ***^,##
No	77.5	74.0; 80.8	77.9	74.2; 81.6	70.8	65.7; 76.5	77.5	76.3; 78.7
Yes	22.5	19.1; 25.9	22.1	18.4; 25.8	29.2	24.1; 34.2	22.5	21.3; 23.8
Anhedonia ^,*^,#,##
No	95.6	93.5; 97.8	96.8	95.0; 98.7	83.3	78.9; 87.2	78.6	77.5; 79.8
Yes	4.4	2.7; 60.4	3.2	1.7; 4.8	16.7	12.5; 20.8	21.4	20.3; 22.5
Number of long sick-leaves episodes during training *
No	91.8	89.5; 94.1	95.1	93.2; 97.0	-		-
Yes (> 7 days)	8.2	5.9; 10.5	4.9	2.9; 6.8
Personality	Mean	SD	Mean	SD
Neuroticism	23.0	6.2	22.8	6.2
Extraversion	40.5	6.4	41.2	4.9
Open experience *	41.5	6.2	42.5	5.4
Agreeableness	51.2	6.1	51.3	4.8
Conscientiousness *	44.1	6.0	45.0	5.7

Exposure to traumatic and stressful events	2014 Cohort baseline		2017 Cohort baseline		2014 Cohort follow up		Brazilian adults
Exposure to traumatic and stressful events	%	95%CI	%	95%CI	%	95%CI	%	95%CI
Previous work as emergency professional *
No	89.9	87.4; 92.4	96.3	94.7; 98.0	-		-
Yes	10.1	7.6; 12.6	3.7	2.0; 5.3
Direct exposure to traumatic events
No	49.6	45.2; 54.0	54.8	50.4; 59.2	-		-
Yes	50.4	46.0; 54.8	45.2	40.8; 49.6
Indirect exposure to traumatic events *
No	14.5	11.4; 17.6	19.7	16.2; 23.2	-		-
Yes	85.5	82.2; 88.6	80.3	76.8; 83.8
Exposure at work to traumatic events *
No	82.3	79.0; 85.7	94.3	92.3; 96.4	-		-
Yes	17.7	14.3; 21.0	5.7	3.6; 7.7
Exposure to stressful life events
No	55.0	50.9; 59.1	53.9	49.4; 58.3	-		-
Yes	45.0	40.9; 49.1	46.1	41.7; 50.6
Exposure to physical assault ^,^,**^,#,##
No	98.6	97.6; 99.6	98.8	96.5; 99.7	99.7	99.0; 99.9	95.9	95.2; 96.5
Yes	1.4	0.4; 2.4	1.2	0.2; 2.2	0.3	0.0; 0.9	4.1	3.5; 4.8
Hospitalization due to accident or illness ^,*^,#
No	97.9	96.7; 99.1	97.2	95.7; 98.6	94.2	91.6; 96.8	94.1	93.4; 94.7
Yes	2.1	0.9; 3.3	2.8	1.4; 4.3	5.8	3.2; 8.4	5.9	5.3; 6.6

Variables	M	SD	1	2	3	4	5	6	7	8	9	10	11	12
1. Neuroticism T0	23.0	6.2	(0.73)	-0.39 *	0.02	-0.37 *	-0.44 *	-0.06	0.06	-0.12 **	-0.16 *	0.08	0.49 *	0.19 *
2. Extroversion T0	40.5	5.8		(0.68)	0.29 *	0.46 *	0.45 *	-0.11 **	-0.02	0.12 **	0.11	-0.01	-0.24 *	-0.16 *
3. Openness T0	41.5	5.9			(0.51)	0.16 *	0.09 *	-0.08	0.04	0.02	-0.03	0.06	0.08	-0.08
4. Agreeableness T0	51.2	5.5				(0.72)	0.51 *	-0.01	-0.06	0.13 **	0.11	-0.11	-0.34 *	-0.21 *
5. Conscientiousness T0	44.5	5.9					(0.84)	0.15 **	0.02	0.24 *	0.18 *	-0.09	-0.29 *	-0.23 *
6. Operational trauma T1	21.3	4.8						(0.84)	0.19 *	0.3 ***	0.2 ***	-0.05	0.04	-0.05
7. Job demands T1	13.3	2.6							(0.71)	-0.01	-0.32 *	0.18 *	0.27 *	0.17 *
8. Job control T1	16.9	2.6								(0.63)	0.4 *	-0.10	-0.14 **	-0.12 **
9. Social support T1	19.5	3.7									(0.91)	-0.31 *	-0.31 *	-0.22 *
10. Life events T1	1.0	1.2										(0.42)	0.25 *	0.27 *
11. PTSS T0	22.7	6.4											(0.86)	0.43 *
12. PTSS T1	8.2	10.9												(0.94)

Step	Predictors	PTSS T1
1	Gender	-0.10
	Age	0-.03
	∆R²	0.02
2	Neuroticism T0	0.10
	Extroversion T0	0.03
	Openness T0	-0.03
	Agreeableness T0	-0.11
	Conscientiousness T0	-0.15
	∆R²	0.07 *
	PTSS T0	0.42 **
	∆R²	0.14 *
3	Operational trauma T1	0.14 ***
	Job demands T1	0.09
	Job control T1	-0.02
	Social support T1	-0.22 *
	Life events T1	0.07
	∆R²	0.09 **

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[1] Correspondence
A. G. Vasconcelos Rua Desembargador Afonso Lages 341, Belo Horizonte, MG 31260-250, Brasil. alinagomide@gmail.com