Abstract
Despite known individual-level facilitators of cancer screening, the impact of work-related organizational-level characteristics on cancer screening is unknown particularly in the firefighter workforce who is experiencing a disproportionate burden of cancer. We examine the association between fire service organizational-level factors and implementation of cancer screening activities within Florida fire departments. We used a cross-sectional observational study design to survey fire department leaders attending the Florida Fire Chiefs' Association Health and Safety conference about cancer screening activities implemented by their fire departments. Measures assessing organizational-level characteristics include: fire department workforce size, total health and safety officers, fire department geographic location, employment type, leadership support and capacity. Among the 126 fire departments participating (response rate = 47.7%), approximately 44% reported some type of cancer screening activity in the 12 months prior to survey administration. The proportion of fire departments with two or more health and safety officers was significantly greater among those with cancer screening activities as compared with departments without cancer screening activities (46.3% vs. 24.2%; P = 0.016). There were no statistical differences noted for cancer screening activities among all other organizational-level characteristics including workforce size, fire department geographic location, employment type, leadership support, and individual capacity measures. Most organizational-level characteristics of a fire department evaluated in this study were not associated with cancer screening activities; however, having two or more dedicated health and safety officers supports the delivery of cancer screening activities. These officers may be a key to improving availability of cancer screening activities at work.
Introduction
Firefighters in the United States are at increased risk of site-specific cancers from the respiratory, digestive, and urinary tract organ systems when compared with the general U.S. population (1, 2). The International Agency for Research on Cancer (IARC) reviewed 42 studies and reported significant risks for non-Hodgkin lymphoma and prostatic and testicular cancers, concluding that firefighter exposures were possibly carcinogenic to humans (Group 2B; refs. 3, 4). Firefighters can be exposed to hazardous contaminants from fires that are known or suspected to cause cancer (5, 6). These contaminants include combustion by-products generated during a fire, such as benzene and formaldehyde, and materials in debris including asbestos from older structures (7–9). While much research and occupational safety efforts are underway to reduce exposures to workplace carcinogens (10, 11), little is known about facilitators and barriers to cancer screening in firefighters, a necessary component to cancer control and prevention.
The work environment can provide a unique space for clinicians and researchers to engage working communities at high-risk for specific cancers to conduct prevention and screening activities. Cancer screening, for example, has been shown to be effective at reducing cancer morbidity and mortality (12–14); however, screening can be complex as it requires interfaces between patients, providers, work, and health care organizations. While there is limited epidemiologic data on cancer screening behaviors among first responders, preliminary data on Florida firefighters self-reporting prostate-specific antigen (PSA) and colorectal cancer screening show lower rates of cancer screening when compared with the general U.S. male population (15, 16). One qualitative study exploring perceptions of health and cancer risk among Florida firefighters documented that firefighter would preference a visit to a doctor for an injury rather than for routine care or for chronic disease management (17). Despite the known individual-level facilitators of cancer screening, the impact of work-related organizational-level characteristics on cancer screening is unknown, particularly in the firefighter workforce, which is experiencing a disproportionate burden of cancer. Existing resources within a fire department can be leveraged to expand the scope of fire department initiatives to address cancer risk factors and disparities. Changes to the physical and social characteristics of work environments are likely to have greater impact than individual firefighter health education alone.
Few studies explore the role of organizational factors on intra- and interorganizational cancer screening processes (18–20). There is a growing literature demonstrating associations between structural and functional factors of organizations with their willingness or readiness to adopt and implement a variety of innovations, including some epidemiologic studies that have specifically examined implementation of organizational-level cancer screening and occupational safety and health (OSH) standards (21–23). Results from these studies suggest that organizational factors such as company size, industrial sector, existence of top leadership support, and organizational capacity, in terms of dedicated staff, budgets, and committees can influence the implementation of OSH and cancer screening.
Observational studies conducted in different job settings have documented specific risk and protective cancer factors that could be modified through efforts targeting the work environment, including facilities, services, and policies (14). For example, risk factors in the work environment include exposure to known carcinogens (e.g., diesel exhaust), higher levels of which are often permitted in the workplace compared with the general community environment (24). Others include behaviors (e.g., alcohol or tobacco use) or chronic conditions (e.g., obesity) that may increase cancer risk (25). There are also protective factors (e.g., physical activity, fitness, diet) that may reduce cancer risk (26, 27). These factors affect a high percentage of U.S. workers, so even small changes leveraged through the work environment could have a large impact at the population level. In the U.S. fire service, little is known about risk and protective factors that support cancer screening from an organizational-level perspective.
This study is responsive to the call from the Centers for Disease Control and Prevention (CDC)'s worksite wellness initiatives to evaluate the impact of risk and protective factors for cancer control and prevention in the work environment as it relates to firefighters (28, 29). It investigates relationships between fire department organizational characteristics (i.e., workforce size, health/safety officers, geographic location, leadership support and capacity) and the extent of implementation of cancer screening activities in 126 Florida fire departments. We also examine whether high numbers of OSH activities are correlated with cancer screening activities in fire departments.
Materials and Methods
Study design and participant recruitment
This cross-sectional observational study is part of a larger statewide firefighter cancer initiative aimed at preventing and reducing the burden of cancer within the Florida fire service (30). Our research team distributed an anonymous paper-based survey among registered attendees of the Florida Fire Chiefs' Association Health and Safety Conference held on December 4–6, 2017 in Orlando, Florida. The annual conference is open to all firefighters in the State of Florida and is comprised of attendees from senior level positions within Florida fire services, including the fire chiefs, assistant chiefs, fire prevention officers, shift officers, individual firefighters/paramedics, health and safety officers, and fire investigators. A booth strategically placed next to the registration desk and adjacent to the only main conference entry way was staffed by our research team who approached conference attendees to complete the survey. The conference organizers made an announcement to attendees on the main stage twice a day encouraging completion of the survey. No incentive was provided to the firefighter for completing the survey.
Survey instrument and study measures
We designed a 56-item survey instrument, Firefighter Assessment of Strategies Trumping Cancer (FAST-C), with the goal of documenting organizational-level characteristics of the fire department that impact occupational health and safety, cancer screening, and decontamination practices in firefighters. Measures were adapted from previously validated or administered surveys of occupational safety and health and worksite health promotion (21, 23, 31).
Cancer screening
We assessed cancer screening activities, our primary outcome, in the fire department with the question “During the last 12 months, did the fire department offer firefighters cancer screenings (e.g., full body skin exams, colorectal, or cervical cancer screening)?” with dichotomous response option (yes, no).
Implementation of OSH
The questions assessing the number of OSH activities were based on the Occupational Safety and Health Administration's (OSHA) 1995 Occupational Safety and Health Program Evaluation Profile survey previously used by the research team (31). While the original OSHA survey contained 10 items, the survey instrument administered in this study used 9 items following content/face validity testing with a smaller group of firefighters prior to administering the final survey at the firefighter health and safety conference. The extent of implementation of OSH programs and policies refers to the number of “yes” responses to 9 questions with a dichotomous response option of yes = 1 or no = 0), and the sum of the responses to 9 questions from each firefighter could range from 0 to 10.
Organizational characteristics
We considered six organizational characteristics of the fire department: (i) workforce size, (ii) total health and safety officers, (iii) fire department geographic location, (iv) employment type, (v) leadership support, and (vi) occupational health and safety capacity. Workforce size was defined as the number of active firefighters (nonadministrative positions) employed within the fire department. Total health and safety officers was defined as the total number of health and safety officers employed within the fire department, where the officer is a firefighter whose job function includes the health and safety of their fire department workforce. The geographic location where the fire department is located within Florida was operationalized as rural area only, urban area only, suburban area only and mixed area (urban, suburban, and rural). Employment type was a measure assessing if the fire department was comprised of career firefighters only, volunteer only or mixed career/volunteer. Leadership support measures for OSH and cancer screening were adapted from Cinite and colleagues (32); separate questions inquired whether there was a person in top fire department leadership who was a strong supporter of OSH and cancer screening. Response options were dichotomous (yes, no). We assessed the fire department's capacity to enact OSH and cancer screening activities using three items: dedicated budgets, staff, and fire department committees. Each of these three items' response options was dichotomous (yes = 1, no = 0). We estimated each individual capacity item separately. Following Hannon and colleagues (22), we combined each of the three individual items to develop a OSH capacity sum score (possible range of 0–3). We estimated means OSH implementation and capacity scores stratified by availability of a cancer screening activity.
Data analysis
Descriptives and correlations.
We conducted explanatory statistical data analyses for continuous variables, expressed as mean with its SE, and for categorical variables, represented as frequency and percent of the sample. We examined the main outcome of fire department cancer screening activity stratified by workforce size, total health and safety officers, fire department geographic location, employment type, leadership support, and capacity. For categorical data, we conducted χ2 analyses to compare groups, and used t tests for continuous data. We used a Levene test of homogeneity of variance across groups for each variable (33). We used Pearson product–moment correlation to examine the relationship between number of OSH and organizational continuous characteristics in fire departments.
Bivariate analyses.
We conducted a two-way ANOVA to determine whether significant differences existed for either main effect of number of capacity factors (range of 0–3) or existence of leadership support for implementation of OSH, while adjusting for the other significant factor. After running the model, if either of the main effects (i.e., leadership support or capacity) was significant, we used a Tukey post hoc test to identify specific group differences. The significance level is set to 5%. All statistical analyses were done on SPSS v21 (IBM Corp). This study research protocol was reviewed and approved by the University's Institutional Review Board.
Results
A total of 264 firefighters registered to attend the Florida Fire Chiefs' Association 2017 Health and Safety conference of which 126 firefighters from unique Florida fire departments submitted the survey (response rate = 47.7%). Among respondents, the firefighters were employed as shift officers (36.5%), Fire department chiefs (24.6%), health and safety officer (20.6%), firefighter/paramedic (13.5%), fire prevention (3.2%), and fire investigator (1.6%).
Cancer screening and organizational characteristics
Approximately 44% of Florida fire services report some type of cancer screening activity in the 12-month prior to survey administration (Table 1). The proportion of fire departments with two or more health and safety officers was significantly greater for those with cancer screening activities as compared with those departments without cancer screening activities (46.3% vs. 24.2%; P = 0.016). There were no statistical differences noted for cancer screening activities among all other organizational-level characteristics including workforce size, fire department geographic location, employment type, leadership support, and individual capacity measures. Organizational support for cancer screening includes top leadership support and capacity (defined as having a dedicated budget, staff, committee for OSH). As indicated in Table 1, fire departments with cancer screening activities reported a higher mean implementation (5.54 ± 1.98 vs. 4.67 ± 2.37; P = 0.031) and capacity score (mean score = 1.91 ± 0.75 SEs vs. 1.44 ± 0.81; P = 0.001) for OSH, as compared with fire departments without any cancer screening activities.
Descriptive organizational characteristics and occupational health and safety implementation activity and capacity of Florida Fire Departments by availability of cancer screening program (n = 126)
OSH polices and cancer screening
All fire departments with cancer screening activities reported that they had at least one OSH activity; the number of OSH activities ranged from 1 to 8 (Table 2). Over 75% of fire departments with cancer screening reported having at least 5 OSH policies, training efforts, and programs. The proportion of fire departments who updated their OSH program regularly was significantly greater for those with cancer screening activities than for departments without cancer screening activities (74.5% vs. 48.4%; P = 0.005). Across all OSH policies, programs, and practices, slightly fewer fire departments without cancer screening programs reported having supervisors or managers who provided OSH training (41.8%) compared with fire departments with cancer screening (43.1%).
Occupational safety and health and worksite health promotion programs, policies, and practices among Florida Fire Departments, December 2017 (n = 126)
In bivariate analyses, only total health and safety officers, OSH implementation, and capacity were significantly related to implementation of cancer screening activities. Hence, these were the three sole organizational characteristics investigated in ANOVA. As indicated in Table 3, having higher capacity factors (P < 0.001), higher OSH implementation (P = 0.031) and higher numbers of OSH health and safety officers (P = 0.006) are individually associated with cancer screening activity implementation. In the last column in Table 3, we see that a fire department's capacity factors (OSH committee, dedicated staff, budget) explain 8.2% of the variance found in cancer screening activity offerings and availability of health and safety officers accounts for 26.3% of the variance.
Organizational characteristics associated with fire departments offering cancer screening activities: analyses of variance of Florida Fire Departments (n = 126)
Discussion
Fire departments across the United States have become increasingly concerned about the unique and disproportionate burden of specific cancer types observed in the fire service (34). This attention to cancer in the fire service has given rise law to U.S. House Resolution 931, the Firefighter Cancer Registry Act of 2018 establishing a national cancer registry dedicated to fire fighters. Increasing attention of cancer control and prevention efforts beyond individual level health education interventions such as those that leverage the work environment and organizational characteristics for cancer screening are needed. This study contributes to our knowledge that workforce size, geographic location, and employment type does not impact cancer screening activities conducted in the work environment. Fire department leadership often taut their rural location, or workforce size as barriers to implementing a cancer screening activity in their fire department (35, 36). However data from this study suggest that only having two or more dedicated health and safety officers supports the delivery of cancer screening activities in the fire service.
As part of a comprehensive occupational health and safety program, we found that across nine organizational policies, programs and practices assessed, an OSH program that is updated regularly occurred more frequently among fire departments with cancer screening activities than those without cancer screening activities. This finding is consistent with those of McLellan and colleagues, who similarly in small- to medium-sized general U.S. businesses found that implementation ability was high among businesses that have an OSH program and update the program periodically (21). We found that fire departments offering cancer screening activities were able to implement on average one more OSH activity than those without a cancer screening activities suggesting that occupational health and safety activities are related to cancer screening activity in a fire department.
Workforce size was not significantly related to the implementation of cancer screening activities within the fire department. This observation contrasts with the results of other epidemiologic studies' in that implementation levels of OSH activities increase with increasing workforce size (23, 37, 38). Poston and colleagues found in a national U.S. study on fire department health promotion programs that the size of the fire department did not impact their ability to have a strong wellness program (39). This observation supports the notion that even smaller fire departments can effectively implement occupational health and safety programs as well as health promotion activities like cancer screening when compared with large fire departments. For many cancers, early-stage disease can be effectively treated with good chance for cure, whereas late-stage disease is generally incurable (40). U.S. firefighters, both career and volunteer, generally have high insurance rates, partially mitigating access issues although convenient workplace screening opportunities could further enhance early detection and lower worker compensation costs (41)
While other studies have examined workforce size in relation to implementation of cancer screening and OSH activities (21, 23, 37, 38), this study also investigated the role of health and safety officers and fire department capacity. Similar to other champion model studies (42), the presence of health and safety officers was associated with the availability of cancer screening activities. This observation is supported by the bivariate analyses results that indicate that capacity, and not top leadership support, was significantly associated with a greater proportion of fire departments implementing cancer screening activities. While a fire department with capacity in terms of budget, staff, and a committee appears to have no impact on implementation of cancer screening, having two or more health and safety officers and an OSH program that is updated periodically is associated with cancer screening activities with the fire services. Health and Safety officers in a fire department are encouraged to translate the OSH vision into tangible organizational resources, including budgets, committees, and staff to further the success of cancer screening implementation efforts.
This observational study is not without limitations. All study measures are self-report where fire department leadership, depending on the rank and level of leadership, may not be acutely aware of all policies, programs, and activities occurring department wide. The primary outcome measure of cancer screening activities is limited in that the quality of the cancer screening activity nor the success of the activity was measured by the survey instrument. In addition, all OSH activities listed in the survey were given an equal weight in analyses, which could be a limitation. We are not aware of a weighting schema for individual OSH activities that would weigh the strength of an OSH activity higher than another; however, we evaluated activities from recognized firefighter sources. An additional limitation is that no standard measures exist for top leadership support and capacity, although the capacity item we use has been used previously in the OSH literature. Finally, the measure on cancer screening activity is broad; a more specific measure assessing specific types of cancer screening would have been more insightful.
The study has several strengths. This study contributes to understanding the impact organizational characteristics have on cancer screening and OSH activities by focusing on fire department in one large populous state. While there is a national firefighter cancer cohort study assessing individual-level factors, there is no national firefighter organizational-level study assessing cancer screening barriers and facilitators, therefore it is important to investigate implementation at state and regional levels to begin to develop an understanding of these organizational-level factors on cancer screening issues. The focus on fire department–wide organizational activities is also novel and important as most firefighters are volunteers and have different organizational barriers when compared with career firefighters. The fire departments surveyed came from a wide variety of geographic locations in Florida, including all seven emergency response regions, and were representative of Florida fire departments. Finally, this investigation is the first to examine organizational-level characteristics of leadership support and capacity and their important relationships to cancer screening activities.
Conclusions
Our study contributes important information about organizational-level factors influencing the implementation of cancer screening activities in fire departments. Comparable data across U.S. fire departments would be useful; however, current national firefighters' studies have strictly focused on individual firefighter behaviors and practices and traditionally have not included organizational-level characteristics. Existing national firefighter health and cancer surveys should include questions about organizational characteristics and factors related to implementation of cancer screening activities that could support a comprehensive cancer control and prevention program for U.S. firefighters. Our results suggest that further investigation of the roles of fire department capacity and health and safety officers for implementation of cancer screening activities is warranted.
Disclosure of Potential Conflicts of Interest
No potential conflicts of interest were disclosed.
Authors' Contributions
Conception and design: A.J. Caban-Martinez, N.S. Solle, K.M. Santiago, C.G. Bator, E. Kobetz
Development of methodology: A.J. Caban-Martinez, N.S. Solle, K.M. Santiago
Acquisition of data (provided animals, acquired and managed patients, provided facilities, etc.): A.J. Caban-Martinez, K.M. Santiago, C.G. Bator, E. Kobetz
Analysis and interpretation of data (e.g., statistical analysis, biostatistics, computational analysis): A.J. Caban-Martinez, T. Koru-Sengul, C.G. Bator, F.A. Babinec, J. Halas
Writing, review, and/or revision of the manuscript: A.J. Caban-Martinez, N.S. Solle, K.M. Santiago, D.J. Lee, T. Koru-Sengul, F.A. Babinec, J. Halas, E. Kobetz
Administrative, technical, or material support (i.e., reporting or organizing data, constructing databases): A.J. Caban-Martinez, K.M. Santiago, C.G. Bator
Study supervision: A.J. Caban-Martinez, K.M. Santiago, C.G. Bator, E. Kobetz
Acknowledgments
The authors would like to thank the Florida first responders who took the time and effort to participate in this research project. In addition, we would like thank Debbie Pringle from Coral Springs - Parkland Fire Department and “Denise Holley” from the Florida Fire Chiefs' Association for assisting the research team logistics on survey administration while at the conference. This work was supported by State of Florida appropriation #2382A to the University of Miami (UM) Sylvester Comprehensive Cancer Center.
The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby marked advertisement in accordance with 18 U.S.C. Section 1734 solely to indicate this fact.
- Received December 18, 2018.
- Revision received January 22, 2019.
- Accepted March 8, 2019.
- Published first March 14, 2019.
- ©2019 American Association for Cancer Research.
References
Volume 12, Issue 5
