Berkeley City Council
March 22, 2022

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19 Tandy, Wulf, & Young, 2013; Zimmerman, 2012). These demands include being able to apprehend and restrain individuals. In over 75% of police apprehensions, suspect resistance is moderate to strong, and the average amount of time to subdue a subject varies between 30 seconds and 2 minutes (Quigley, 2008). Such tasks require effort, which can be physically challenging (Anderson et al., 2001).

When police officers encounter high-risk situations, certain physiological patterns can be predicted and measured. Armstrong et al. (2014) documented that an officer’s average heart rate throughout a shift was 22 beats a minute above an average resting heart rate. As officers encountered simulated use of force, their heart rates increased an average of 40 beats per minute. This demonstrates extra stress placed on the heart, which affects an officer both psychologically and physically (McCraty & Atkinson, 2012).

Even though police officer work patterns are characterized mainly by relatively long periods of low-level activity, occasionally, short periods of high-intensity activity are needed. To safely and effectively perform police functions, it is necessary to maintain a certain amount of physical fitness throughout one’s career. Though much of the job can be executed independent of physical fitness, some tasks will require certain levels of physical fitness. However, how fit officers need to be and what factors can be used to predict successful performance are debatable (Collingwood, Hoffman, & Smith, 2004; Dillern, Jenssen, Lagestad, Nygard, & Ingebrigtsen, 2014). Ensuring that those in public safety are physically ready for their jobs can aid officers in performing their duties more safely. This effort can be enhanced by stressing positive lifestyle habits, as these habits help decrease health risks, improve quality of life, and assist agencies in reducing their liability by controlling risks and associated costs (FitForce, Inc., 2010).

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20 A police department should ensure safe working practices, especially given that their officers face potentially violent situations (Bissett et al., 2012; Bonneau & Brown, 1995; Brown et al., 2013; “Fitness Tests Will Help Police,” 2012). For example, arrests are commonplace among police officers, and research suggests that higher fitness levels affect arrest encounters positively. Because the physical task most frequently demanded of officers is arrest, upholding some level of fitness is important (Dillern et al., 2014).

Anderson et al. (2001) collected data observations that justify certain occupational requirements for police work. These observations included officers having to physically control suspects. Testing of physical abilities include tasks wherein officers have to get to a problem, control the problem, and remove the problem through appropriate simulated measures. Such observations, along with self-report surveys, can be accurately measured and tested (Anderson et al., 2001).

The last several decades have demonstrated much change in police work, such as the encouragement of alternative methods of dispute resolution and new computer and technology skills. Therefore, some have questioned whether physical abilities are still important for police officers (Bonneau & Brown, 1995). The fact remains, however, that there is nothing routine about police work, and it often requires short, intense encounters.

Therefore, officers should train to condition their bodies to adapt and perform under various unpredictable conditions (Zagaria, 2007).

Police are subjected to both physical and psychological stress as they relate to the workplace (Phadke, Khan, Iqbal, & Ramakrishnan, 2014). Thus, another important component of officer fitness is psychological fitness for duty. Fitness-for-duty evaluations (FFDEs) can be and are used when situations exist wherein officers must be

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21 psychologically ready for duty. The key object of this type of evaluation is to reduce an agency’s liability (Fischler et al., 2011). Physical skills can be quite crucial when they are needed; they also have an important function from a psychological perspective for officers. Officers report that good physical skills can provide them with confidence as well as security when interacting with the public (Lagestad, 2012), therefore tying physical and psychological well-being to one another. However, it could be argued that the police job itself does not cause poor officer fitness and health; rather, a lack of agency fitness standards and programs is likely to blame (FitForce, Inc., 2010). This idea is explored later.

Work-Related Injuries
The Occupational Safety and Health (OSH) Act of 1970 requires certain employers to maintain work-related injury and illness records (Form 300) and note the extent and severity of each case. An injury or illness is considered work-related if an event or exposure in the work environment caused or contributed to the condition or significantly aggravated a preexisting condition (OSHA, n.d.). Trends show that recently, law enforcement has experienced a reduction in health and fitness in the United States, making officers even more prone to work-related injuries and illness (Quigley, 2008).

In fact, duty leave due to injury appears to be at a high rate among public safety workers, a large portion of whom are police officers (Violanti et al., 2013). Because police work can be physically demanding, stressful, and dangerous, officers have among the highest rates of injury and illness of all occupations (BLS, 2014). National accident, injury, and illness data show that 20% of an average police agency’s workforce is

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22 responsible for 80% of accident costs, suggesting that this small percentage of least-fit officers is responsible for a large majority of injuries (Quigley, 2008). The leading causes of work injuries for police officers are falls, trips/slips, and mental stress (Ferguson, Prenzler, Sarre, & de Caires, 2011). Lower fitness levels tend to be associated with an increase in injury risk (Orr, Stierli, Hinton, & Steele, 2013), but the impacts of increased levels of fitness are a little less clear (Pronk, 2015). In a study of Milwaukee police officers across a 13-year span, Brandl and Stroshine (2012) found that accidents accounted for the majority of lost time from work when medical attention was sought.

Physical Fitness Policies in Law Enforcement
There are limited sources that define or identify law enforcement agencies in North Carolina that have a fitness policy, and if so, to what level or extent. One recent study in the state found that among 145 police agencies, a significant association between fitness maintenance policies and officer injury existed (Fortenbery, 2016). However, to further explore specific policy requirements and reasons for implementation, each agency would have to be contacted to learn more about standing policies. Research has been conducted in other states that provide a better picture of fitness policy prevalence. For example, among 37 police departments in Michigan, only three (8%) had a policy regulating fitness standards or programs (Williams, 2002). Policies on fitness standards vary; sometimes they are vague, but other times they are quite specific, with noncompliance potentially leading to termination (Burlington Police Department [BPD], 2010; Farley, 2011). The intent of this study was to explore this issue further within the state of North Carolina.

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23 Fitness is something for employers to contemplate because it is directly related to work performance, productivity, and health care costs, which are all factors to consider in operating an effective agency. It is important to the employee because it affects income, health, and other quality-of-life issues. If employers would indeed benefit from fit officers, they should promote fitness backed by supportive policy, adhering to both state and federal regulations (Pronk, 2015).

The Legalities of Fitness Standards
In a general sense, employers are responsible for protecting their employees against physical harm that may reasonably be expected to arise in employment. If the necessary duty of care is not exercised, employers can be at risk for litigation (Rayson, 2000). Yet if certain measures or tests are to be used, those standards need to be job- related. Fitness tests should define the physical abilities needed in police work both objectively and realistically (Anderson et al., 2001) while complying with laws prohibiting discrimination (U.S. EEOC, n.d.). Data need to back up any standards or tests that are used in order to demonstrate that such standards or tests are correlated to job performance. Such data are available and should be used to document certain components of fitness such as body composition, cardiovascular endurance, anaerobic power, flexibility, strength, and agility in relation to the job (Collingwood et al., 2004; FitForce, Inc., 2010; Smith & Tooker, 2011). Ensuring that tasks are relevant to the industry assists in designing specific occupational standards that help to keep officers prepared to meet their job demands and avoid injury (McGill et al., 2013).

Several factors can hamper an employer’s use of physical fitness tests because of disputes over the standards used; however, testing is necessary in this work environment

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24 (Adams et al., 2014). One thing that an employer needs to take into consideration is Title VII of the Civil Rights Acts of 1964 and 1991. Title VII states, “it shall be an unlawful employment practice for an employer … to discriminate against any individual with respect to his compensation, terms, conditions, or privileges of employment, because of such individual’s race, color, religion, sex, or national origin.” This includes discrimination in relation to any aspect of employment, including certain terms and conditions of employment (U.S. EEOC, n.d.). An agency cannot have different fitness standards for men and women if they are doing the same job because this can have a legal effect of invalidating the standards (Means et al., 2011b). If an agency is to terminate police officers based on specific agency fitness standards, the legality of this matter depends on how the court interprets Title VII (Guffey et al., 2014).

Courts are increasingly scrutinizing departmental physical agility requirements, particularly if entry-level officers and incumbent officers are held to different standards; however, health-based standards are more likely to be upheld, as they focus on general fitness assessments (Bissett et al., 2012). The Americans with Disabilities Act (ADA) of 1990 also needs to be considered when making physical or medical inquiries of incumbent employees. If such inquiries are made, they need to be based on objective reasoning (Fischler et al., 2011). In Tennessee v. Garner (1985), police use of deadly force to apprehend fleeing felons was restricted. This ruling had an implication that officers should be adequately fit to both pursue and subdue suspects without having to depend on deadly force. A similar ruling in Parker v. District of Columbia (1988) found that an unfit officer was unable to affect an arrest and so resorted to the use of deadly

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25 force. Based on these rulings, administrators should consider adequate monitoring of officer fitness levels.

Proper medical and health screenings can help reduce litigation risk (Lee & Mallory, 2004). Employers need to adhere to all regulations that protect the health and safety of its workers (Pronk, 2015). If departments hire officers who possess sub- standard strength and ability skills, they could be held liable as it is the employer’s responsibility to demonstrate that the physical standards required are based on essential elements of the job, and that the performance demanded is reasonable (Bissett et al., 2012; Bonneau & Brown, 1995).

Physical Fitness Testing
A consensus says that law enforcement officers should maintain at least some level of physical fitness, but what that level is varies according to who one asks, and how should this be assessed? (Means, Lowry, & Hoffman, 2011a). Recruit training is designed to prepare officers for duty, and so includes tasks that relate to daily police work (Orr et al., 2013). Across the state of North Carolina, law enforcement training academies include a standard fitness component as part of training. Research recommends that academy curricula be based on needs-assessment as well as job-task analysis using the most practical approach to testing content (Bonneau & Brown, 1995; Caro, 2011; Plat et al., 2011). Personal and team accomplishments are usually stressed because it is important for both personal well-being and survival in a profession that comes with high levels of stress and danger (Ebling, 2002). Police officers are taught in ways that correlate to the type of work they do (Zagaria, 2007) but sometimes contrary to what are found once in a place of employment.

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26 Fitness testing in theory is a way to motivate police personnel to maintain a fitness level to promote job readiness (Adams et al., 2014). However, standards first need to be established, and justified as to their significance. Several fitness activities have been identified as commonly being used in police work. These include running, jumping, lifting, carrying, and dragging to name a few. It is critical that testing assesses all physical abilities that are required of the job, or what Bonneau and Brown (1995) refer to as occupational fitness. While officers may utilize aerobic endurance on duty, research suggests that physiological demands may also be anaerobic in nature (Orr et al., 2013). Fitness can be measured using various physiological standards, from oxygen consumption to physical strength (Bonneau & Brown, 1995).

It is recommended that fitness assessments are conducted to determine and record officers’ fitness levels. Scores can then be compared to norms and standards (Cooper Institute, 2014) and should be evaluated on up-to-date standards (Schulze, 2012).

Cooper Institute standards are used by many agencies, as well as academy fitness training. The Cooper Institute is renowned for its history, research, and publication in ability/agility testing. Often a 50th percentile is used as a fitness benchmark (Bissett et al., 2012), as minimum fitness standards are directly related to adequate job performance (Pronk, 2015) because higher injury risk was associated with factors such as older age, slower run times, and lower self-rated physical activity (including aerobic exercise) (Knapik et al., 2011).

There is no ‘one size fits all’ when it comes to required fitness standards for officers. Individual departments need to consider the job demands and the working environment. There is some debate about whether the programs should be voluntary.

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27 Bissett et al. (2012) do not believe that voluntary programs are going to be enough.

Williams (2002) agrees and emphasizes that without a policy, even resources provided often go unused without any kind of incentive behind it. That is why a policy would be most beneficial because it regulates fitness of individual officers. However, FitForce, Inc. (2010) would argue that a voluntary fitness/wellness program would be the most effective and cost effective approach. Another approach might be to use a worker’s health surveillance (WHS) to detect health effects resulting from occupational exposure.

A WHS can assist employees in safely and healthfully meeting job requirements. The goal is to periodically monitor employees and detect adverse health effects as early as possible so preventative measures can be taken (Plat et al., 2011). For these purposes, wellness is defined as “those purposeful actions taken to attain and maintain optimal health and fitness” (Smith & Tooker, 2011, p. 3).

To standardize a job-related test, one’s ability to perform the physical demands of core police tasks needs to be examined (Strating, Bakker, Dijkstra, Lemmink, & Groothoff, 2010). Both construct and criterion validations are accepted as job-related standards. Criterion such as job descriptions and injury reports can be examined to identify these standards. And because job tasks are not often performed in isolation, utilizing sequence events makes them more real-world situations (Collingwood et al., 2002). Job simulations are often used in testing to measure multiple physical abilities.

These types of tests are beneficial because they possess a higher content validity than simple, single ability tests. But, job simulations can only predict performance within its administered context (Courtright, McCormick, Postlethwaite, Reeves, & Mount, 2013).

Collingwood et al. (2004) used multivariate regression to demonstrate validity as it

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28 relates to fitness activities. Regression analysis indicated that a group of specific test items can be good predictors of job tasks, and multiple primary physical factors that they analyzed met these criterions. Data must support and demonstrate a correlation between fitness testing and any job criterion performance, thereby establishing continuity in standards. It is incumbent standards that are key to successful job-related testing (Means et al., 2011a).

One concern about testing is that some criteria used by law enforcement agencies are argued to be discriminatory, particularly against sex. Large male-female differences exist within certain physical abilities. Therefore, test validity needs to demonstrate and defend its use, or different performance measures for women and men need to be developed based on normed scores (Anderson et al., 2001; Bissett et al., 2012; Courtright et al., 2013). Yet caution is needed when using gendered tests because separate standards could reinforce biases when it comes to gender since standards tend to establish biological sex and not biologically determined physical ability (Schulze, 2012). But, Means et al. (2011b) argue that whatever levels of fitness are required to perform the essential minimum physical functions of the job, they are achievable by most, regardless of gender or age, with as little as three hours of training per week. Another concern is tests that are used for employment selection generally focus on entry-level skills and ability. But a disjunction seems to exist if certain physical abilities are deemed essential to the job, and incumbent officers are not expected to also maintain these abilities (Bissett et al., 2012). The challenging part is that no matter what the demographics are of the police officer, the fundamental tasks to be performed on the job are the same (Bonneau &

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29 Brown, 1995), even though women and older persons tend to test lower or slower (Strating et al., 2010).

Fitness standards for law enforcement officers should be tested to ensure that both new and incumbent officers possess the physical abilities to perform necessary tasks of the job. Standards should be developed, and training programs should be provided so that all officers have the access to and knowledge of skills needed to maintain personal fitness throughout their career (Means et al., 2011a). Such tests are important because those who do not meet job-related demands tend to perform lower, have more injuries, and more absenteeism (Collingwood et al., 2004; Courtright et al., 2013), all which can equate to reduced resources available. Lower levels of physical activity have been associated with absenteeism in the workplace, therefore employers should implement programs that will promote healthy activity levels (Pronk, 2009; Steinhardt, Greenhow, & Stewart, 1991).

Even administrators have recognized the need not only for officer fitness, but for lasting fitness maintenance programs (Lee & Mallory, 2004). Perhaps mandatory standards are not necessarily the answer, but the solution could be mandatory testing (Panos, 2010).

Police Officer Physical Abilities Test (POPAT)
There are no national guidelines for physical fitness tests of police cadets, though most academies require some type of fitness standard (Schulze, 2012). In North Carolina, that standard is POPAT. The POPAT has been scientifically validated as being job specific, as it measures certain abilities that are required for general police duties (Anderson et al., 2001; North Carolina Department of Justice, 2015). In North Carolina,

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30 for over 20 years, BLET students have been required to demonstrate job-related physical ability competencies as a condition of graduation. This test consists of a series of tasks that are designed to assess the physical abilities necessary to effectively perform the job of a police officer. The tasks were developed to mirror real situations that an officer might encounter on the job (North Carolina Department of Justice, 2015).

In 1998 the North Carolina Justice Academy (NCJA, 2000) POPAT subcommittee was specifically tasked with examining and evaluating various options as they related to the proposed POPAT. They were then to develop as well as deliver recommendations for using POPAT as a physical fitness measure (pass/fail) of the BLET program. In April of 2000, the committee agreed to adopt the POPAT report for several reasons. First, they felt such a test was reasonable, fair, and trainable. It was also deemed to be safe, practical, and consistent. The skills included in the POPAT were related to task analysis conducted in 1998 and the committee justified each of the following according to this task analysis. To be completed in seven minutes and twenty seconds (7:20) or less in duty belt and gear, cadets were to do the following:

1. Verbally recall street location

2. Exit police vehicle from seat belted position and run 200 yards

3. Pull a 150-pound person from vehicle and drag them 50 feet

4. Run up and down a five-step staircase three times

5. Push open and go through a 50-pound weighted door

6. Do 20 push-ups and twenty sit-ups

7. Run up and down a five-step staircase three times

8. Crawl through a 25-foot culvert

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31 9. Do 20 push-ups and twenty sit-ups

10. Run 200 yards and return to vehicle

11. Drag a 150-pound person 50 feet

12. Verbally recall street names (NCJA, 2000).

The committee rationalized that the POPAT was reasonable and consisted of tasks that officers might perform while on duty. Officers need to be able to respond to multiple activities that include speed, agility, balance and stamina, and the POPAT was seen as a representation and combination of a variety of skills that may be required of an officer (NCJA, 2000). For example, the Burlington Police Department (2010) utilizes biannual POPAT testing of newly sworn officers as of January 2014. Collingwood et al. (2004) identified many of the same underlying and predictive fitness activities as they pertain to the POPAT. The primary factors identified include absolute upper-body strength (pushups), agility, anaerobic power (1.5 mile run), and anaerobic power (300-meter run).

Their data indicates that certain physical activities can help determine a police officer’s capability to perform essential tasks.

In 2008 another job analysis gave credence to altering the former POPAT test, which became effective for all BLET students starting in the fall of 2015. The scientific validation of the “new and improved” POPAT yielded a 95% confidence level. The test was designed to differentiate between individuals who can and cannot perform certain physical functions of a police officer’s job at an identified adequate level of proficiency (North Carolina Department of Justice, 2015). The new test consists of two scenarios.

Scenario 1 (chase and apprehension, to be completed in six minutes (6:00) or less wearing a ballistic vest), is as follows:

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32 1. From a seated position, run 40 feet and back twice

2. Run 60 feet and return, with a 4-foot broad jump, 4 foot “fence” climb, and 2 feet high crawl obstacle in between

3. Roll a 100-pound dummy three times

4. Do 20 push-ups

5. Conduct another three-repetition dummy roll drill

6. Run 60 feet and return, with a 4-foot broad jump, 4 foot “fence” climb, and 2 feet high crawl obstacle in between

7. On step box, take 30 steps up and down

8. Conduct a three-repetition roll drill

9. Do 20 push-ups

10. Conduct a three-repetition roll drill (North Carolina Department of Justice, 2015).

Scenario 2 (rescue, to be completed in three minutes (3:00) or less wearing a ballistic vest), is as follows:

1. Run 50 feet and back twice

2. On step box, take 30 steps up and down

3. Run 50 feet and back twice

4. Drag a 175-pound dummy 25 feet and back (North Carolina Department of Justice, 2015).

Training programs should constantly be assessed to ensure they are both current and relevant. Violence is prevalent in the current environment and so training should be as realistic as possible. Officers should be provided with solid, research-based scenarios

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33 that prepare them for an evolving and changing climate within which they work (Miller, 2015).

The Impact of Fitness for Duty
Though police work tends to largely be sedentary (Ramey et al., 2014; Steinhardt et al., 1991) and not always physically demanding, when officers need to engage in physical agility, their fitness level may very well be a determining factor of the outcome (Brown et al., 2013). Shiftwork is often an inevitable circumstance of police work that can contribute to this issue. Wirtz and Nachreiner (2012) concluded that the exposure to shiftwork had a significant impact on fitness for duty, particularly after 20-22 years working in this environment. An effective fitness program can help counteract some of the adverse health impacts of sedentary and shift work (Pronk, 2015). The inability to maintain resilience can impair judgment and the ability to make decisions. Results can potentially lead to inappropriate application of force which can carry lasting consequences such as compromising public safety, injuries and even lawsuits (McCraty & Atkinson, 2012; Zimmerman, 2012) as discussed earlier.

An unfit officer increases the probability of injury both to him or herself and to others (Boyce, Hiatt, & Jones, 1992). Unfit officers can be a liability in several ways.

First, officers may use excessive force to compensate for an inability to use physical restraints, or second, unfit officers may cause other officers to be injured because they are unable to render adequate assistance. This not only presents potential legal exposure for those officers, but vicarious liability can also be extended to that officer’s agency (Guffey et al., 2014).

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34 Improved physical ability profits both the officer and employer. Officers profit from increased job performance, reduced stress and better mental preparation. Agencies benefit in terms of fiscal responsibility and efficiency (Quigley, 2008). Employers are the ones who bear the financial consequences of reduced work productivity and increased medical spending, and therefore are likely to benefit from a healthier workforce.

Investing in and providing both means and incentives would seem to gives an employer a return on their investment (van Dongen et al., 2011). Boyce, Jones, and Hiatt (1991) set out to investigate this relationship between physical fitness and work absences in police officers. But they found that the extent to which fitness predicts absenteeism is actually low. This is contrary to other and more up-to-date research, but does provide a valid focus to distinguish between absenteeism versus injuries.

Studies involving law enforcement officers indicate that more fit and active officers report 40-70% less absenteeism. This equates to a cost savings to the agency, therefore demonstrating that agency money spent on workplace fitness and wellness saves dollars as fit officers miss fewer work days (Smith, 2010; Smith & Tooker, 2011).

These employees are also more highly productive (FitForce, Inc., 2010). Local and state governments across the United States are spending more money on policing than they did several decades ago. In a time where budget cuts are more likely than budget increases, a way to reduce some policing costs is to maximize productivity (Gascon & Foglesong, 2010). Unfit employees cost agencies lost days from work and increased insurance costs (Panos, 2010). Since a lack of fitness standards can be costly it leaves to wonder why departments do not set standards and provide training (Williams, 2002).

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35 But, physical activity and fitness have a preventive effect on these factors (Sassen, Kok, Schaalma, Kiers, & Vanhees, 2010; Wright et al., 2011) which can have implications for the workplace. Therefore, the need to stay healthy requires both diet and exercise in order to maximize fitness level (Guffey et al., 2014; Hartley et al., 2011; McCraty & Atkinson, 2012). For example, interventions such as increasing physical activity and fitness can help improve cardiovascular risks (Sassen et al., 2010) as higher levels of cardiovascular fitness can be related to reduced absenteeism (Steinhardt et al., 1991).

Even though officer fitness is important, fitness alone is not sufficient. The focus should be on more than one risk factor to reap beneficial outcomes (Gerber et al., 2013).

A healthy weight and physically active lifestyle are important for general health. But fitness also matters as it pertains to disease and illness prevention, as well as social and economic concerns in the workplace. However, since the workplace is but one component of life, a broader fitness perspective does need to extend beyond the workplace (Pronk, 2015). In fact, Ramey et al. (2014) and Boyce et al. (1992) found that police were more active off-duty, or unsupervised, than at work, or supervised. Work is connected to the home and the community. Health behaviors extend across all environments and are difficult to separate (Hymel et al., 2011).

Injuries pose a public health problem and effective strategies could help decrease this burden. But, public health practice has been a bit slow to address injury prevention (Stier et al., 2012), perhaps because of reluctance. Law enforcement agencies may be reluctant to partner with public health agencies because they are unclear on mandates.

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36 However, North Carolina has taken initiative by partnering with various agencies to identify resources and responsibilities (Stier et al., 2012).

The advantages of a healthier, fitter, and energetic workforce include lowering absenteeism rates related to sickness. This is worth the necessary measures (“Fitness Tests,” 2012). Past studies have demonstrated that a correlation exists between the length of time on the police job and a decline in health and fitness (Panos, 2010) so agencies could benefit from a fit workforce in both performance and health. This leads to greater contributions and enables communities to invest elsewhere (Pronk, 2015). Exercise can help with the stress associated with the law enforcement job and contribute to more positive coping. Agencies recognize that fitness is important for their officers, and encourage maintaining a healthy and adequate fitness level, but many find it difficult to implement some kind of fitness program (Ebling, 2002; Lagestad, 2012). When police officers engage in physical activity on a regular basis, it better prepares them to deal with work-related situations requiring physical force, and helps strengthen their psychological well-being (Lagestad, 2012).

If departments choose to test and evaluate officer fitness, programs need to be put into place that can assist officers to both attain and maintain a necessary fitness level for the job (Bonneau & Brown, 1995). Of several national voluntary fitness and wellness programs, data showed improvements in overall fitness, therefore increasing productivity and reducing both absenteeism and worker’s compensation claims (Quigley, 2008).

Health, fitness, and wellness should be included in a program as they are related and complement one another (Smith & Tooker, 2011). A supervised and job-specific exercise program for police officers improved fitness after 6 months in men and women.

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37 However, a continued supervised exercise program is likely needed to maintain long-term health benefits (Rossomanno, Herrick, Kirk, & Kirk, 2012). Fitness and wellness programs also show to increase loyalty, generally improve morale, and reduce turnover (Quigley, 2008; Smith & Tooker, 2011).

Ferguson et al. (2011) suggested that prevention should be a focus of future work, given the critical role that police officers play in preventing crime, maintaining order, and providing emergency services. Prevention begins in the police academy. If police candidates are not screened and fail to successfully perform certain duties, this can result in injury/disability, turnover, and poor productivity which can have both a human and economic cost (Anderson et al., 2001). In total, medical expenses and lost productivity from injuries are estimated to exceed $400 billion (Stier et al., 2012). Law enforcement agencies take up a piece of this pie.

The Cooper Institute (2014) believes that fitness in law enforcement is necessary because it relates to (1) the ability of officers to perform essential job functions, (2) minimizing excessive force situations, (3) minimizing health risks associate with the police job, and (4) meeting the legal requirements to avoid litigation. To emphasize these points, an agency that does not address officer fitness requirements is susceptible to litigation for negligent (1) hiring of those not fit to do the job, (2) training to help officers maintain their physical capabilities of job demands, and (3) supervision of such individuals (Williams, 2002). Ensuring fitness for work can lead to increased quality of production, both decreased absenteeism and turnover, and lower medical costs which reduces incidence of injury (Rayson, 2000).

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38 Fitness Resources for the Workplace
Once employed officers continue to train in many areas such as legal updates, driving, firearms, and defensive tactics to name a few. Yet most often fitness is not one of those areas of focus (Williams, 2002) although we know its benefits. Pronk (2009) demonstrated that most fitness interventions resulted in positive effects among employees. Research supports that comprehensive, multicomponent physical interventions lead to significant improvements in health, as well as reduce absenteeism (Steinhardt et al., 1991). This generates positive return for the employer (Pronk, 2009).

There are potential resources available to agencies within the state, but little is known as to whether agencies are aware of, or are using such resources.

North Carolina is one of seven states that mandate full-scope injury prevention programs. General Statute 130A-224 provides that “the Department of Health and Human Services establish and administer a statewide injury prevention program and designate the Division of Public Health as the lead agency for injury prevention activities.” Injuries are often predictable and preventable, but laws by themselves cannot prevent injuries, action must be taken (Stier et al., 2012). Both health protection and promotional programs need to be intertwined to promote a healthier and safer workforce.

A healthier workforce will be safer and a safer workforce will be healthier (Hymel et al., 2011). Program intervention should extend outside the workplace, utilizing community resources as well through incentives (Pronk, 2015).

Under the auspices of the U.S. Department of Health and Human Services (HHS, 2015), the Prevention and Public Health Fund provides workforce wellness program opportunities. It emphasizes prevention initiatives and provides grants to small

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39 employers to assist with the implementation of such programs. The pressure is placed on both workers and employers as health costs skyrocket. Health measures aimed at improving the workforce could significantly have a long-term impact and save billions in costs (Hymel et al., 2011). According to Harte, Mahieu, Mallett, Norville, & VanderWerf (2011), health impacts workforce productivity, and if an organization integrates a wellness benefit program, it can achieve a substantial saving between 15- 35%.

Leadership in Law Enforcement
Improving the overall health of law enforcement officers can provide economic motivation for an agency. However, an officer who meets physical fitness standards upon initial employment does not necessarily ensure overall health maintenance throughout a career (Bissett et al., 2012). An important part of one’s well-being lies within the work environment. Health can be affected by work conditions, and although different types of stress exist, physical stress affects health the most (Phadke et al., 2014).

A well-oriented and trained leadership is essential to a successful fitness program (FitForce, Inc., 2010). Workplace health promotion programs should engage employees and show long-term impacts on health and costs, as well as minimize absenteeism. But absenteeism needs to be specifically defined as it is difficult to measure (Steinhardt et al., 1991). Programs should operate in an environment that embodies best practices (Pronk, 2015) but to be successful, physical programs need top management support, exist in a supportive environment, and engage all levels of management (Pronk, 2009).

How officers are managed strongly influence their commitment and employees are more likely to contribute in positive ways, meaning cost benefits through lower

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40 absenteeism and lower turnover rates (Dick, 2011). Police leader management is linked to agency organization and is influenced by norms. These para-military organizations tend to have high levels of organizational commitment because the culture has strong obligational norms. A supervisor that wishes to implement a fitness program has a good chance of earning support from higher up. This type of support may have many benefits, including on-duty benefits (Williams, 2002). Physical fitness is part of a culture and can be supported from the top (i.e.: chief) down (Panos, 2010). Even when it comes to stress, quality work-peer relationships along with organization support are correlated with stress among police officers, and stress can affect the physical health and well-being of officers (Papazoglou & Andersen, 2014). Absence from work can be influenced by work structure. Policy that institutes any kind of health circumstances needs to consider the employer’s structural influences and advocate presenteeism and its desirable outcomes.

Organizations seeking to minimize absenteeism should perhaps focus on not only is an individual fit for work, but does the work fit the individual (Irvine, 2011).

Because public sector agencies (like law enforcement) have little or no incentive to change, leaders might question the relevance of supporting change. However, hiring processes and training academies change to adapt to the changing needs of the new generation; therefore, administrative practices and leadership also needs to change.

Agencies need to balance both constancy and predictability that change must be adapted (Batts, Smoot, & Scrivner, 2012; Dick, 2011).

Within public decision-making, most ethical codes rely on internal, organizational controls (Franklin & Raadschelders, 2004). Franklin and Raadschelders (2004) found that both structural and procedural controls provide guidance to the decision-making

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41 process. The vertical chain-of-command can lend itself to isolated functions and so law enforcement agencies need to be proactive in their leadership to provide continuous and cross-functional development (Putney & Holmes, 2008). Supervisors, particularly executive management needs to both participate and support any fitness program (Quigley, 2008; Smith & Tooker, 2011). They should promote an appropriate culture of wellness that encourages employees to maintain a healthy lifestyle (Zimmerman, 2012).

This commences the planning process.

Strategic planning in public sector agencies takes a “big picture” approach. It uses futuristic thinking and analyzes courses of action to ensure that an agency’s effectiveness and abilities add to public value (Poister, 2010). Policy initiation is crucial to decision-making where first identifying background and problems are critical because there is always a gap between a problem and acting based on a decision (Political Science Notes, 2013). Commitment from top-level leadership is essential to successful strategic planning and execution as strategic planning needs to be consistent with top executive management style and the reality of an organization’s decision-making process (Ugboro, Obeng, & Spann, 2011; Williams, 2002).

As good and practical as a fitness program may seem, the budget process may present dilemmas for its progress. Decisions made might favor some but not other values, but choices must be made (Franklin & Raadschelders, 2004). Civil servants play an important role in choices made during policy-making. Since they do not hold political office, they are not held to as intense political pressure because of reelection interests, so they bring a solid perspective to the playing field (Franklin & Raadschelders, 2004).

Public agencies need to make an effort to be inclusive of their external stakeholders and

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42 involve them in the decision-making process, for example using surveys, focus groups or even forums (Poister, 2010). When it comes to fitness, levels in the workplace can directly or indirectly impact the community and society as it enhances local as well as national security and safety (Pronk, 2015).

Effective leadership will be critical in order for a police fitness program to be successful (Lee & Mallory, 2004). Strategy needs to be formulated by both top executives and line managers if planning is to be supported. This can be done by monitoring performance measures, aligning budgets with strategic plans, and communicating strategies to all stakeholders (Poister, 2010). Both internal and external partnerships are essential in collaborative efforts to ensure employee quality (Putney & Holmes, 2015).

Rational Choice Theory
Rational choice theory as initially described by Becker (1976) was applied to law enforcement leadership decision-making, attempting to explain the absence (or presence) of physical fitness standards at law enforcement agencies in North Carolina. Rational choice theory holds that individuals act as utility maximizers that include individual preferences and self-interest. More specifically in the social sciences, both individual behavior and social interaction affect the policymaking processes in government (Jones et al., 2006). It can be applied dynamically in which planning for the future and considering the present are included (Green, 2002). Analysis will usually begin with a question and can be worked through in several steps:

1. identifying relevant agents and constraints,

2. determining and applying consistent rules for each agent,

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43 3. exploring predictions and experience, and

4. drawing conclusions (Green, 2002).

Rational is applied in social sciences as meaning that choices made reflect the most preferable and feasible alternatives that are available. The theory can be applied by focusing on three main components. (1) Maximizing utility is the assumption of rational choice theory, or in other words, choosing the preferred alternative that benefits the most. (2) Another element of the theory is constraints, or things/circumstances that exist in which making a choice is necessary, therefore also taking into the consideration the (3) environment in which choices are made. Theory follows the pursuit of specific objectives at an organization (Green, 2002). Even though policy is made by organizations, it is the interacting of human decision makers and individual choice that put such policy into action (Jones et al., 2006).

Rational choice theory contains several characteristics including that decision makers first, hold both ranked and ordered preferences for outcomes, and second, possess the necessary information to connect choices to outcomes to optimize preferred outcomes (Jones et al., 2006). Decisions are not made in a vacuum but they are made to serve definite purposes. Rationality needs to be important in the decision-making process, or public utility will be adversely affected (Political Science Notes, 2013).

Evidence suggests that a supportive organizational work environment has both a positive and direct influence on organizational commitment. In other words, commitment is influenced by the way employees are managed rather than by job demands (Dick, 2011). Rational choice theory, though most often an approach used to explain economics, can be applied to understand human behavior within the social

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44 sciences. It begins with making choices by one or more individual decision-making units and assumes such choices are made based on larger “typical” or “representative” populations. Analysis then examines how individual choices interact with one another to produce outcomes (Green, 2002).

Summary
A clear majority of police academies in the United States use some physical agility test that tests mostly for strength and endurance. Some agencies use agility tests, either as a pre-employment condition and/or a condition of continued employment. The reason is that these tests are most widely accepted as underlying factors that attribute to physical demands placed on police officers. Even though agility tests are commonly used to screen police applicants, the requirements of officers to maintain a standard of health and fitness are fewer (Bissett et al., 2012; Glassman, 2003), particularly among North Carolina agencies (Fortenbery, 2016). Studies consistently show that physical fitness does have a direct impact on reducing injuries as well as improving personal well-being and work performance (Quigley, 2008). Police agency policies do not reflect the findings for various, unknown reasons. Aside from personal health and agency cost benefits, a certain fitness level also portrays a more professional image, and contribute to reducing excessive use of force incidents (Williams, 2002). Both topics are worth pursuing in future research as it relates to officer fitness. But for now, chapter 3 presents the current research’s methodological approach.

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45 Chapter 3: Research Method
Introduction
The North Carolina Criminal Justice Commission mandates employment and training standards for law enforcement officers in the state. The Commission also regulates the required standards for the BLET program, including physical fitness.

However, fitness is not one of the employment guidelines. A foundation for fitness is laid, but only across law enforcement training academies in the state; policy does not mandate fitness once officers are employed. Commission responsibilities do not extend into the agencies themselves when it comes to requiring certain fitness standards to remain employed. Therefore, there is a gap in academic research as to why some agencies continue fitness standards and others do not, particularly given knowledge of the benefits of healthy, fit individuals. Further, although the Department of Labor requires all industries to report work-related injuries to OSHA, it is not known whether there is some kind of connection or correlation between injured officers and set agency fitness standards. If there is, this information could both inform agencies across the state and contribute to the literature pertaining to North Carolina law enforcement agencies. The intent of the current mixed-methods study was to fill this gap in the literature, described in more detail as follows.

Research Design
This research study consisted of a mixed-methods approach using both quantitative and qualitative methodologies. A quantitative approach provided the statistics necessary to determine whether a relationship or correlation existed between fitness policies and work-related absenteeism and injuries among a small sample of law

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46 enforcement agencies in North Carolina. It did not provide an explanation as to why some agencies have instituted physical fitness policies and some have not. When research points not only to individual benefits, but agency benefits as well, the question is left unanswered as to why some policies are not in place. Therefore, the second phase of this study used a more detailed case study through a qualitative design to better understand this gap. For example, the use of a questionnaire explores who knows something as well as what is known (Bergman, 2008) within an agency.

Case Study
A multisite case study approach guided this research, as data collection involved multiple sources of information including policy and injury report documents and interview questionnaires (Creswell, 2013). Upon gaining appropriate approval to participate, six law enforcement agencies were examined to try to gain an understanding of why policy differences exist among agencies that have no (or voluntary) fitness policies, agencies that require some participation in fitness activities, and agencies that have very stringent and rigid policy. These agencies were selected purposely according to size and type of policy. In this study, a particular area of interest was determining whether a relationship existed between fitness policy and work injury and absenteeism, so it was necessary to first collect descriptive, quantitative data. The qualitative aspect further entailed examination of policy decision-making and implementation using interviews.

Research questions were considered before determining the order in which elements of the methodology were applied because order can influence results. For the current study, I used a concurrent QUAN -> QUAL design. The quantitative component

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47 was one stage of the concurrent design and was conducted at the same time as the qualitative component, which included the use of interview responses (Nastasi, 2010) to understand administrative roles in policy decision-making. The justification for the quantitative aspect was that I would use a sample to first determine whether a relationship existed between the independent and dependent variables, controlling for level of policy.

I then examined how policy decision-making might influence any significant findings (see Figure 1).

Figure 1. Concurrent/triangulation design. Adopted from The Mixed Methods Reader (p. 380), by V. L. Plano Clark & J. W. Creswell, 2008, Thousand Oaks, CA: SAGE.

Copyright 2008 by Sage Publications, Inc.

Role of the Researcher
Having been a North Carolina BLET fitness instructor for 14 years, I have become aware that a gap exists between police academy fitness standards and law enforcement agency fitness standards in the state. In an effort to address this lack of understanding, I conducted an extensive search of academic and trade literature, looking at studies both within the United States and worldwide that pertained to police officer

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48 fitness, wellness, and job injuries. As I became familiar with this literature, I found that the same questions remained unanswered, and these questions consequently became the focus of this study. First, I sought to determine whether fitness requirements that carried over to law enforcement employment were related in any way to the prevalence of workplace injuries and/or absenteeism. Second, I sought to identify who made agency fitness policy decisions and what the rationale and influences were behind these policies.

To address whether fitness policy correlated with injuries and absenteeism, it was important to narrow down the field of study while remaining focused on law enforcement agencies in North Carolina. Because of time and cost constraints, it was necessary to identify a manageable sample of agencies within the state. Because past qualitative studies in this area had used a sample of six, it was determined that a sample of six agencies would serve the purpose of this study and answer the research questions being sought. First, agency fitness policies and OSHA 300A summary forms were examined and analyzed for significant variance. Second, an interview was conducted with a training officer at each site to gain a better understanding of the policy-making process.

This meant first constructing a questionnaire in which the content addressed these questions. Feedback from a local advisory committee was sought to ensure that questions were on target regarding the information being pursued.

The next step was to identify and contact six law enforcement agencies in the Piedmont Triad area that were willing to participate. I explained the study before I gained the necessary permission to review the requested documents. Phone contacts were made until two agencies from each policy level category (voluntary, changed or

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49 progressive, and mandatory over a 5-year period) were identified. Mid-size agencies (serving a population of 50,000 – 500,000) were used for fair comparison purposes.

Creswell (2013) suggested that qualitative researchers collect their own data.

Therefore, after gaining appropriate permission from the participating agencies, I made an appointment with each to both review documents and interview training officers.

Anonymity was guaranteed, and results will be shared with the agencies after final analysis. It was my responsibility as the researcher to collect and analyze all data once appropriate Institutional Review Board approval had been secured. No individuals or agencies encountered any expenses related to participating in this study. Any expenses incurred because of this research were my responsibility as the researcher, including any supplies, travel, and documentation needed.

Research Population and Sample
According to the North Carolina Justice Academy (NCJA, n.d.), there are approximately 495 police agencies in the state, including state, municipal, county, hospital/healthcare, college, and airport agencies. The state is made up of 100 counties and is geographically divided into three regions: the Mountains, the Piedmont, and the Coastal Plains (see Appendix A). The Piedmont is the middle region of the state. Within this region, the Piedmont Triad consists of 12 counties (Piedmont Triad Regional Council, 2012). This region was the focus of the current study from which a sample was drawn for location and convenience purposes. In selecting a sample of law enforcement agencies located within the Piedmont Triad region (see Appendix B), the focus was on “midsize” populated areas (50,000–500,000 people) as defined by the International Association of Chiefs of Police (IACP, 2014). The IACP (2014) has cited nearly 700

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50 midsize cities in the United States, hosting a combined population of more than 75 million. This is almost twice the population of major cities (those with populations greater than 500,000) and represents nearly one-quarter of the total U.S. population.

These jurisdictions comprise a significant proportion of the American urban and suburban landscape. This is a significant presence in the American municipal landscape, and it has not been until recently that midsize cities and their associated police agencies have been a distinct area of focus for research, funding, or advocacy as recognized by the IACP in 2009. Since then, research priorities have focused on the needs and interests of midsized populations. For these reasons, I chose to draw a sample for the current research from this population base. Appendix C identifies the counties, cities, and state agencies that met the above criteria within the Piedmont Triad population base.

A sample of six midsize municipal North Carolina law enforcement agencies in the Piedmont Triad region was used for convenience. Two agencies from each of the following categories were studied: (1) no mandated/voluntary fitness policy over the last 5 years, (2) a changed or progressive fitness policy over the last 5 years, and (3) a continued mandated fitness policy over the last 5 years (2011-2015). Using these midsized agencies provided adequate data and statistics, from which any significant relationships in variance should be evident between policy level and injury and absenteeism reports. Using three categories allowed for comparison across policy type, and a 5-year period allowed for examination across multiple years to ascertain whether trends remained consistent.

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51 Instrumentation
The documents collected at each agency consisted of instituted fitness standards for the years 2011-2015, as well as OSHA 300A forms documenting missed work days due to injuries or absenteeism for the same 5-year period. Hard copies of all documents have been kept in a locked file drawer within my personal home office, with the key located in a place only known to and accessible by me in order to protect confidentiality.

Any electronic documents or correspondence related to this study have been saved on a designated research flash drive and kept in my locked possession. Backup electronic documents have been stored in a password-protected folder on my personal home computer. All records will be kept for a minimum of 5 years.

The second part of the study continued with interviews. Interviews are commonly used in qualitative research (Creswell, 2013). Interview questions addressed the following: (1) the rationale for department officer fitness standards, (2) whether policy was intended to address work-related injuries and illnesses, and (3) how policy decisions were made and influenced. Question wording in an interview is important because how questions are asked can affect the responses they elicit (Patton, 2002). The question categories listed above seemed appropriate to explore differences in policies, whether policy might contribute to work-related injury rates, and what influenced policy. The interview process allowed for the flexibility of emergent design with the questions covered. It allowed for both the interviewer and interviewee to include any additional information that emerged and was pertinent to the study through the use of open-ended questions.

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52 Ethical Procedures and Considerations
The Code of Ethics of the Academy of Criminal Justice Sciences (ACJS, n.d.) was the guiding code for this study. This organization addresses the scientific discipline of those who study, research, teach, or practice in the criminal justice field. Criminal justice professionals are expected to adhere to the Code of Ethics when applying ethical behavior in their everyday professional activities. General principles within the code include recognizing the potential for harm, not knowingly placing the well-being of oneself or others in jeopardy within professional work, and ensuring anonymity in research (ACJS, n.d.). These principles guide law enforcement administrators, organizations, and educators, specifically within their policy and field practices.

Protection of Human Participants
Protecting human participants is important in research. In this study, data collection through interviews required human participation and contact. Because interviews were conducted at law enforcement agencies, physical safety was assumed.

Because the content was not of a personal nature, there were no anticipated psychological effects. Participants were briefed on informed consent and privacy and were advised that at any time, they could elect to cease study participation without any repercussions.

Informed Consent
Informed consent is a process that includes telling participants who is conducting a study as well as why they were selected to take part. Rudestam and Newton (2007) provided practical guidelines on how to proceed with informed consent. When asking subjects to participate, it is appropriate to indicate the time commitment and any benefits that can be expected to arise from the study. In this case, the time commitment was

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53 approximately 2 hours per agency, and participants will be provided with both the data analysis and questionnaire results. Potential risks needed to be addressed, which in this study were minimal to none in relation to participants’ agreement to provide policy documentation as well as injury statistics reports. All agencies that agreed to participate were asked to sign and return a letter of cooperation.

Right to Privacy
Participants are entitled to confidentiality (ACJS, n.d.), so it was important to protect the identity of all agencies and any names associated with them. Protection of both agency and individual identities was achieved by assigning each agency a number (e.g., Agency 1, Agency 2, or Training Officer from Agency 1, etc.). Allowing participants to ask questions and ensuring that participation was voluntary were also necessary (Rudestam & Newton, 2007) and were emphasized in the research process, both verbally and in writing.

Honesty
Honest communication and reporting of results is essential to ethical research. I engaged in no intentional misrepresentation or misleading action of any kind during the study. High ethical standards were applied, and the results were reported completely and honestly.

Institutional Review Board (IRB)
To ensure that ethical standards were applied, the IRB process served as a critical step in this research. Walden’s IRB ensures that any research conducted under the auspices of the university complies with both ethical standards and federal regulations.

Students, along with their committee members, must submit and receive IRB approval

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54 before collecting any data (Walden, 2010). To comply with Walden IRB requirements, I submitted a completed application prior to seeking participants for this study. Once approved, agency participants were contacted to voluntarily participate in this study.

Data Analysis
Statistical Package for Social Sciences (SPSS) was used to record and analyze the quantitative data to test the study’s hypotheses. Frequencies, variance, standard deviation, and crosstabs were applied to provide a general distribution of descriptive statistics. Analysis of variance (ANOVA) was used in the data analysis to determine the significance of any variance between the study’s variables. If the variables were found to be significantly related, the null hypothesis was rejected. I determined and defined the level of measurement for each variable used, which helped to determine the statistical analyses that were used (Thornton, 2011). In a quantitative analysis in which the aim is to generalize to a larger population, sample size is important. Given that a sample of six was used out of a population of 495, generalization was of course not possible.

Dissemination of Study Findings
The research results in total will be shared with participating agencies as well as the North Carolina Justice Academy and other interested law enforcement agencies in the state. Confidentiality and unanimity were and will be maintained. Personal contact will be made with each agency training officer upon completion of data analysis and results.

Law enforcement trade magazines will be solicited for potential publication, making study results available to this targeted audience.

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55 Validity and Reliability
To establish transferability in the qualitative aspect of this study, Creswell (2013) suggested that sampling is essential, particularly to establish external validity. In this study, purposeful sampling was utilized to select police agencies that made up varying levels of fitness policies. One of the most credible manners to ensure internal validity is through triangulation, or collecting data from various sources such as interviews, questionnaires, and assessing different documentation of data. Triangulation uses different research designs to examine data from different perspectives, which is why interviews were also conducted and included in the study evaluation. Every effort was made both verbally and in writing to ensure that all participants and agencies were respected and appreciated for their time and interest.

Summary
This study used a sample of six North Carolina law enforcement agencies to determine whether fitness policy influenced work-related injuries and absenteeism and what factors contributed to policy decision-making. By first using a quantitative analysis, results yielded whether a significant relationship between policy and injuries and absences among the sample agencies existed. If the null hypothesis was rejected because certain policies were related to fewer work-related injuries and absences, this study will provide support for advocating continued fitness beyond the police academy.

Additional analysis through examination of questionnaire responses determined whether rational choice theory supported policy decision-making, focusing on the utility function. This helped determine what factors contributed (at least partially) to policy and whether decisions being made were personal in nature, or representative of larger

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56 objectives. Organizations constantly undergo change, which can impact leadership. The one recognized as the leader is the one who has the potential and capacity to influence the group (Karp & Helgo, 2008). According to Bennis (2007), leadership is a matter of values. The next chapter discusses the results and how both quantitative and qualitative analyses have contributed to this field of study.

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57 Chapter 4: Results
Introduction
The purpose of this mixed methods study was to test the utility function component of rational choice theory to determine whether it explains fitness policy implementation and whether such policy affects reported work-related injuries and absenteeism among a sample of midsized law enforcement agencies in the Piedmont Triad region of North Carolina. The quantitative portion of the study examined the stringency of agency fitness policy over a 5-year period (2011-2015; independent variable). Injury and absenteeism rates were calculated from OSHA 300A summary forms for each agency within this time frame (dependent variables). A control variable was also used based on whether an agency’s fitness policy changed over this 5-year period, to measure any change in injury and absenteeism rates. The qualitative portion of the study examined the interview responses of training officers at each agency pertaining to fitness policy implementation, decision-making, and rationale. Responses were examined for common themes and whether they represented rational choice theory decision-making.

The research questions that guided this study were the following:

1. What relationship, if any, exists between a North Carolina law enforcement agency’s fitness policy and work-related injuries and absenteeism?

2. When research emphasizes the benefits of maintaining a certain fitness level, particularly for first responders, does the utility function within rational choice theory explain why some North Carolina law enforcement agencies mandate physical fitness requirements for officers and others do not?

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58 3. Are data-driven results of injury or absenteeism an agent or constraint as they pertain to the present fitness policy?
An extensive review of the literature was conducted pertaining to the content of interest, focusing on (but not limited to) current research done in this area over the last 5 years. Previous research focused on officer fitness, physical fitness testing, legal standards, policy implications, work injury and absences, and leadership. Very limited studies were found on law enforcement agencies in North Carolina pertaining to fitness policy, and none were found pertaining to OSHA-reported injuries and absences. Thus, this population became the focus for the current study, particularly when it was known that a gap existed involving state police academies requiring a fitness component while many law enforcement agencies had no such requirements as a condition of employment.

In this chapter, I report on my analysis of the findings from a sample of six law enforcement agencies based on fitness policy standards and change over a 5-year period, as well as yearly reported work-related injuries and absences. Additionally, I discuss how rational choice theory may play a role in fitness policy decision-making at an agency level when the utilitarian concept is applied, thereby explaining the data analysis of each research question that guided the study. In the last chapter, I present conclusions and implications of this research.

The Researcher
Creswell (2013) suggested that researchers provide information about themselves, the IRB process, steps to gaining entry to the sample, and ethics. As the researcher in this study, I had 6 years of experience as a sworn law enforcement officer in North Carolina, as well as 17 years as a criminal justice instructor at a community college. In 2001 and

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59 2002, I became a certified general instructor and specialized physical fitness instructor, respectively, for the BLET program in the state. I was taught and administered the state- mandated fitness testing of cadets based on valid and scientifically tested research pertaining to physical activities that police officers are likely to encounter as part of the job. These credentials allowed me to teach any general curriculum block of instruction within BLET as well as oversee and assess physical fitness activities within the police academy. I routinely tested and evaluated police cadets on the required obstacle courses and fitness assessments, all necessary as a condition of graduation. I wondered why cadets were held to such a high standard of fitness in the police academy, whereas, more times than not, these or any physical requirements were not mandatory conditions of employment at a law enforcement agency. Policy was determined at the agency level, yet who was involved in these decisions, and what was the rationale behind them? This interest and concern for the well-being of officers in terms of wellness and safety followed me into my doctoral studies and thus led to the development of the current study. Therefore, it may appear that I had some bias concerning this topic; however, I made every effort in proposing, conducting, and analyzing this research to present the information in an ethical and objective manner.

Before collecting data, the appropriate and necessary steps were taken based on Walden University’s IRB requirements. An application was submitted to the IRB outlining each step of the proposed research and my plans to protect both the confidentiality and identity of participants. Conditional approval was granted with the understanding that each participant (agency) would sign a letter of cooperation prior to any data collection. I then began contacting each of the agencies within my proposed

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60 population via telephone, soliciting the agencies’ voluntary participation in my study.

After an agency agreed to participate, a signed letter of cooperation was obtained and forwarded to the Walden IRB. Once an e-mail confirmation was received from the IRB, data collection at that agency commenced. A consent form as well as a data use agreement form were also collected from each participating agency and filed in that agency’s electronic and hard files. After the total sample of six was reached, I had the necessary data to begin analyzing both my quantitative and qualitative data.

Setting and Recruitment Process
The population of midsized law enforcement agencies in the Piedmont Triad region of North Carolina totaled 11. An attempt was made to contact the training officers of all 11 agencies by telephone to ask them to participate in this study after I had briefly explained its intent. Several voicemail messages were left and of those agencies that did not respond, a follow up call was made. After reaching the appropriate contact at an agency and explaining my study, the conversation was followed up with an e-mail detailing the study’s purpose, voluntary participation and the necessary information being sought for analysis, along with the need for a signed letter of cooperation if they agreed to participate. If no response was received from an agency within a 2-month period via e-mail, a follow-up e-mail was sent again inviting the agency to participate. After a period of 6 months, six agencies had responded and agreed to participate. For convenience and because of availability, these six law enforcement agencies were used as the nonprobability sample for case study analysis.

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61 Instruments
Several instruments were used to collect data from the sample in the study. For the quantitative aspect of the analysis, a copy of each agency’s fitness policy (see the sample agency fitness policy in Appendix D) was obtained (if such a policy existed) for each of the years 2011-2015. Additionally, a copy of each agency’s OSHA 300A summary form (see Appendix E) was collected for the same 5-year period. A short questionnaire was used to analyze the responses pertaining to the qualitative aspect of the study, to gain a better understanding of the process and factors involved in policy decision-making at an agency.

Statistical Package for the Social Sciences (SPSS, 2015) was used for quantitative analysis to address Research Question 1. The rationale for the choice of statistical test and assumptions associated with the statistic were based on the research question and therefore are discussed in more detail below. Line-item data mining in Windows Excel was used for qualitative analysis to address Research Questions 2 and 3. Responses and themes were explored to test rational choice theory.

Quantitative
Each agency’s physical fitness policy for the years 2011-2015 was coded per policy level and assigned a value; 1 (no policy/voluntary participation), 2 (general policy/voluntary participation), 3 (annual in-service/testing), and 4 (biannual testing); (Means, Lowry, & Hoffman, 2011c). For analysis purposes, each agency was then placed in a category per the stringency level of its fitness policy (from least to greatest) and assigned a value number. Whether policy changed over the years between 2011 and

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62 2015 was also indicated; 1 (no change) and 2 (increased standards) for each agency, each year.

Absence and injury rates were computed for each agency’s OSHA 300A form for the years 2011-2015. The absence rate was computed by dividing the total number of days away from work by the total number of employees multiplied by 100 and rounded to the nearest hundredth. Absence rates ranged from 0–156.14. The injury rate was computed by dividing the total number of injuries by the total number of employees multiplied by 100 and rounded to the nearest hundredth. Injury rates ranged from .82–

14.56. These rate standardizations allowed for comparison across agencies due to the variance in number of employees. See Appendix F for a summary of the quantitative data.

Qualitative
Each training officer (or designee as determined by the agency head) at the six agencies was provided with a questionnaire inquiring about the number of sworn officers within an agency, and whether the agency was accredited by the Commission on Accreditation for Law Enforcement Agencies (CALEA), with the assumption being that those agencies that were CALEA accredited were likely to have some type of fitness policy in place. The questionnaire also included whether an agency had a fitness policy over the 5-year period of 2011-2015, and if so, whether participation in fitness and wellness activities was voluntary or mandated. The remaining five questions were meant to test rational choice theory and address the policy decision-making process. These questions included the following:

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63  What is the rationale behind having/not having a fitness policy in place, or for changing policy?
 Who are involved decision makers in fitness policy?
 What factors determine or affect fitness policy?
 Was policy intended to address work-related injuries and illnesses?  Are you aware that North Carolina provides a full public health mandate that includes injury prevention, and if no, would you want more information, or if yes, was this considered in fitness policy implementation? (See Appendix G.) Qualitative research can be deemed valid using triangulation and member checking (Creswell, 2013), and so at the same time policy and OSHA data were being collected, these questions were reviewed and verified by speaking with the training officer or designee. For data to be considered qualitatively reliable, consistency is important (Creswell, 2013); therefore, the same questions were asked of each agency.

Demographics
For analysis purposes, participants were actual agencies, for which employee demographics were not known, except by raw numbers. This was done to protect the confidentiality of agency employees. Though the questionnaire was completed by one individual employee at the agency, these individual demographics were not recorded, but the employee’s agency responsibilities were noted.

Agency 1
Agency 1 was a county law enforcement agency located in the Piedmont Triad region of North Carolina serving an estimated population of 142,799 (U.S. Census Bureau, n.d.). The number of employees at the agency ranged from 228–262 over the

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64 years 2011–2015. This agency did not have a fitness policy for sworn officers (and so it was voluntary on the employee’s part to participate in any physical fitness activities) during the 5-year period.

Agency 2
Agency 2 was a county law enforcement agency located in the Piedmont Triad region of North Carolina serving an estimated population of 158,276 (U.S. Census Bureau, n.d.). The agency ranged in number of employees from 892–1206 over the years 2011–2015. This agency did not have a fitness policy for sworn officers (and so it was voluntary on the employee’s part to participate in any physical fitness activities) during the 5-year period.

Agency 3
Agency 3 was a municipal law enforcement agency located in the Piedmont Triad region of North Carolina serving an estimated population of 110,268 (U.S. Census Bureau, n.d.). The agency ranged in number of employees from 248–268 over the years 2011–2015. This agency did not have a fitness policy for sworn officers during the 5- year period; however, incentives at either the city or county level were available to employees, though participation to receive these incentives was voluntary.

Agency 4
Agency 4 was a municipal law enforcement agency located in the Piedmont Triad region of North Carolina serving an estimated population of 285,342 (U.S. Census Bureau, n.d.). The agency ranged in number of employees from 881–929 over the years 2011–2015. This agency had a general policy that addressed the necessity of employees maintaining their health to adequately perform job functions. This policy remained the

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65 same over the 5-year period, and several incentives at either the city or county level were available to employees, but participation in these incentive programs was voluntary.

Agency 5
Agency 5 was a county law enforcement agency located in the Piedmont Triad region of North Carolina serving an estimated population of 369,019 (U.S. Census Bureau, n.d.). The agency ranged in number of employees from 230–243 over the years 2011–2015. Over the 5-year period, the agency did require sworn officers to participate in 2 hours of health and wellness in-service training each year, and annual POPAT testing was mandated.

Agency 6
Agency 6 was a municipal law enforcement agency located in the Piedmont Triad region of North Carolina serving an estimated population of 52,472 (U.S. Census Bureau, n.d.). The agency ranged in number of employees from 164–182 over the years 2011– 2015. Over the 5-year period, the agency gradually incorporated a mandated biannual POPAT testing of all sworn officers.

All sites had onsite fitness facilities that employees could use at no charge.

Several agencies also offered either free or discounted memberships at local fitness facilities. The first three agencies with no fitness policy were not CALEA accredited; the last three agencies with written fitness policies were CALEA accredited, as assumed.

Data Collection
The location of the population of interest in this study—the Piedmont Triad region of North Carolina—was purposely selected for convenience purposes as well as the purpose of collecting data from a similar geographical region. Again for consistency

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66 purposes, midsize agencies were also the focus of this study; the total number of agencies fitting these criteria from which to draw a sample was 11. The purpose was initially to capture a total of six agencies for case study analysis, representing three categories of varying fitness policies: two not having any fitness policy in place, or a voluntary policy; two having increased in policy stringency over a 5-year period; and two having strict, mandated fitness standards required for officers. After I had contacted each agency and explained the study, six of the 11 responded with their willingness to participate; however, the categories of policy that they represented were not what I had initially proposed. After mining through the data, I observed that four levels of policy were distinguishable and would make for a more detailed analysis. The quantitative data were made up of policy level, any change of policy within the 5-year period, and OSHA 300A injury and absenteeism summary reports. This information was analyzed to address Research Question 1. The qualitative data were made up of questionnaire responses and were analyzed for common themes to assess, first, whether the utilitarian function within rational choice theory existed (Research Question 2), and second, whether data served as an agent or constraint to current fitness policy (Research Question 3).

Data Analysis
Three research questions guided this study:

RQ 1. What relationship, if any, exists between a North Carolina law enforcement agency’s fitness policy and work-related injuries and absenteeism?
RQ 2. When research emphasizes the benefits of maintaining a certain fitness level, particularly for first responders, does the utility function within rational

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67 choice theory explain why some North Carolina law enforcement agencies mandate physical fitness requirements for officers and others do not? RQ 3. Are data-driven results of injury or absenteeism an agent or constraint as they pertain to the present fitness policy?
Using these questions, the research data were analyzed both quantitatively and qualitatively. Descriptive statistics, crosstabs, one way ANOVA, and an F-test were calculated. Then line analysis data mining with Excel was utilized to test rational choice themes. Per agency policy, agencies were listed in order according to policy stringency, with the first agency listed having no policy or incentives at the top, on down to the last agency listed that had a mandated, biannual testing policy. The policy level (independent variable) for each agency (each of the 5-year period) was coded to form an ordinal variable from 1 – 4; 1 being no fitness policy to 4 requiring biannual fitness testing.

Policy change was used as a control variable, to determine if a change in policy over these years affected injury or absenteeism rates. This was coded ordinally where 1 meant no change from one year to the next, and 2 meant an increase in fitness standards required from one year to the next. Both absent rate and injury rate (ratio, dependent variables) were calculated into standardized rates for comparison purposes. Descriptive statistics are provided for each variable as they describe what the data shows (Trochim, 2006). Table 1 shows the six-agency sample arranged per strictness of policy level.

Policy change indicates from one year to the next whether policy did not change, or increased in required fitness standards.

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68 Table 1

Agency Demographics of Sample
________________________________________________________________________

Variable Labels Level of
measurement Mean SD Range

Agency 1 = Agency 1 ordinal
2 = Agency 2
3 = Agency 3
4 = Agency 4
5 = Agency 5
6 = Agency 6

Policy level (IV) 1 = no policy/ ordinal
voluntary
participation
2 = general policy/
voluntary
participation
3 = annual in-service/
testing
4 = biannual testing

Policy change 1 = no change ordinal
2011-2015 (CV) 2 = increased standards

Absence rate (DV) ratio 31.21 32.91 0-156.14

Injury rate (DV) ratio 6.90 3.17 .82-14.56 ___________________________________________________________________________

Research Question 1
The first research question attempted to determine whether having a strict fitness policy affected work-related injuries or absences. The null hypothesis suggests that no significant relationship exists between the stringency of fitness policy and job-related injuries and absenteeism rates; therefore, the alternative hypothesis suggests that the more stringent a fitness policy is, the lower the job-related injuries and absenteeism rate.

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69 A bivariate correlation could not be conducted because the data violated several assumptions of this analysis. First, variables must be continuous; in the sample both the independent and control variables are ordinal level measurements. A second assumption is that a linear relationship exists between variables, and with this study’s data they do not (which also eliminates the use of partial correlation and linear regression). Another assumption of correlational analyses is that no significant outliers exist which was also not true with the data. A fourth assumption assumes homoscedasticity, and upon conducting a scatterplot of the data, heteroscedasticity was detected, so therefore not suggested that correlation be used in analysis (Laerd Statistics, 2013).

When a group comparison of at least one independent variable is being used, analysis of variance (ANOVA) can be used as a statistical test (Creswell, 2013). For this test, the independent variable should be categorical, and the dependent variable should be continuous, which in this study is the case; therefore, ANOVA was selected as the statistical test to answer Research Question 1. Green and Salkind (2011) state that a one- way ANOVA can be used to analyze data from a quasi-experimental study and the F-test evaluates whether the group means on the dependent variable differ significantly from each other. Then, an overall analysis of variance test can assess whether dependent variable means are significantly different among groups.

In social research, Trochim (2006) advises a statistical power greater than 0.8 in value as a rule of thumb. This means having at least 80 chances out of 100 of finding a relationship when there is one. Statistical power is the ability to detect effects given the variance and sample size (Vogt & Johnson, 2011). Several factors interact to affect power. One is to use a larger sample size, another is to increase the risk of making a

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70 Type I error, or increasing the chance that a relationship is found when it is not there.

This can be done by raising the alpha level (Trochim, 2006). In this study the agency sample size of six is small; however, the total number of employees that the sample represents is over 2700. So, it could be argued that using an alpha level of .05 demonstrates a significant statistical power of .95.

ANOVA
First, a one-way ANOVA was conducted to evaluate the relationship between policy level of an agency and absenteeism rate. The independent variable, the policy level factor, included four levels of fitness policy: no policy/voluntary participation, general policy/voluntary participation, annual in-service/testing, and biannual testing.

The dependent variable was the rate of work days missed each year over the 5-year period of 2011-2015. The ANOVA was significant F(3,27) = 5.02, p < .01. The strength of relationship between policy and absent rate, as assessed by η2 was strong, with policy level accounting for 36% of the variance of the dependent variable.

Next, a one-way ANOVA was conducted to evaluate the relationship between policy level of an agency and injury rate, which was the rate of injuries each year over the same 5-year period. The ANOVA was significant F(3,27) = 6.96, p < .001. The strength of relationship between policy and injury rate, as assessed by η2 was strong, with policy level accounting for 44% of the variance of the dependent variable.

Because the overall ANOVA was significant and there were more than two levels in the independent variable, follow-up tests are usually conducted to evaluate pairwise differences (Green & Salkind, 2011). Therefore, it was decided to conduct follow-up tests of Tukey, REGWQ and Dunnett’s C as suggested by Green and Salkind (2011) to

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71 evaluate pairwise differences among means. Dunnett’s C test does not assume equal variances among the four groups and so these results were used to assess both absenteeism rate and injury rate between policy level. There was no significant difference in the means between any policy level and absent rate. However, there was a significant difference in the means between the following:
 Level 1 policy (no policy/voluntary participation) and Level 3 policy (annual in-service/testing)
 Level 1 policy (no policy/voluntary participation) and Level 4 policy (biannual testing)
 Level 2 policy (general policy/voluntary participation) and Level 3 policy (annual in-service/testing)
 Level 3 policy (annual in-service/testing) and Level 4 policy (biannual testing).

The agencies that required annual in-service and testing showed a greater decrease in injury rates compared to agencies with other policy types. The 95% confidence intervals for the pairwise differences, along with the means and standard deviations for the four policy groups, are reported in Table 2.

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72 Table 2

95% Confidence Intervals of Pairwise Differences in Mean Changes of Injury Rates

Policy level M SD Level 1 Level 2 Level 3
1 – No policy/
voluntary
participation

7.25 3.24
2 – General
policy/voluntary
participation

7.67 1.97 [-3.84, 3.01]
3 – Annual
in-service/testing

3.13 1.51 [.42, 7.82*] [.97, 8.11*]
4 – Biannual
testing

10.79 1.05 [-7.02, -.05*] [-6.49, .25] [-11.39, -3.93*]

A second set of ANOVA were conducted examining the control variable (change in policy). A one-way ANOVA was conducted to evaluate the relationship between policy change and absent rate. The control variable, whether policy changed from one year to the next, included two levels: no change and increased standards. The dependent variable was the rate of work days missed each year over the 5-year period of 2011-2015.

The ANOVA was significant F(1,29) = 14.92, p < .001. The strength of relationship between policy change and absent rate, as assessed by η2 was strong, with policy change accounting for 34% of the variance of the dependent variable.

A one-way ANOVA was conducted to evaluate the relationship between policy change and injury rate, which was the rate of injuries each year over the same 5-year period. The ANOVA was significant F(1,29) = 7.02, p < .01. The strength of relationship between policy change and injury rate, as assessed by η2 was strong, with policy change accounting for 20% of the variance of the dependent variable.

The interpretation of the current data has been evaluated on ANOVA analyses. In conclusion, to answer whether a relationship exists between a North Carolina law

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73 enforcement agency’s fitness policy and work-related injuries and absenteeism, the analyses assumes there is a relationship, therefore rejecting the null hypothesis and accepting the alternative hypothesis.

Research Question 2
Research Question 2 attempted to test whether the utilitarian function of rational choice theory explained why specific fitness policies were in place. In other words, was policy decision the preferred alternative that would benefit agency employees most? Several questions in the agency questionnaire were designed to address this.

The first question inquired about the rationale behind having/not having a fitness policy in place, or the reason for changing policy. Agencies had varying responses. Of those agencies that had a fitness policy, improving employee wellness and productivity, along with increasing officer safety were common responses. Agency 6 identified several motivational factors to include:
 reducing long-term medical costs for employees
 improving employee wellness and productivity
 increasing officer safety
 increasing the life span of employees
Agency 4 identified a standard operating procedure in which their objective was to “develop and maintain a level of fitness in police personnel and to ensure their ability to accomplish assigned duties and provide satisfactory job performance without undue risk of injury or fatigue.” The change in policy for Agency 5 was due to a Sheriff initiative to improve the overall health of employees. Of the agencies that did not have a fitness policy, one indicated that it was “due to case law, cost, manpower, buy in from

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74 administration, and law suits.” Having no policy may be impacted of Title VII of the Civil Rights Act which requires all employers with more than 15 employees to refrain from policies that discriminate against specified categories of individuals (U.S. EEOC, n.d.). Title VII can be ambiguous and many standards have not been interpreted by the Supreme Court. Even federal circuit courts differ on these decisions. Since the courts cannot clearly define these standards, it can burden administrations with continued monitoring of court decisions and legislation. Under Title VII, physical fitness standards face scrutiny when they might discriminate against a protected group (for example females, individuals over 55 years of age). Employees must demonstrate that the practice is job-related and necessary. Therefore, in justifying physical fitness requirements, can it be justified as a necessity of law enforcement work? To demonstrate this, administrators must show a significant relationship between the physical fitness requirement and job responsibilities (Brooks, 2001). Agency 2 indicated that “the agency was in the process of reviewing and updating several policies and have not addressed this issue yet”, and Agency 3 reported that “physical fitness policy had never been addressed.” The next question asked who was involved in the policy decision-making process.

Not surprisingly, all responded that the agency head (Chief of Police or Sheriff) were the final decision makers. However, of those involved with the input process, responses ranged from few individuals within the agency to larger committees that included members outside of the agency. Four agencies indicated that decision makers on such policy came from within the agency such as executive staff, administration (directors, commanders) and other employees. Two agencies also included decision makers outside of the agency itself such as occupational health staff, human resources director, city

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75 manager, and city attorney. There was no consistency in agency type as far as who was included in decision-making. Or in other words, municipal agencies were just as likely as county agencies to involve personnel outside of the agency in policy decision-making.

The last question asked to address Research Question 2 sought to determine what factors affected fitness policy decision-making. Common responses included manpower, cost, and resources. Some were also concerned with the legality of such a policy and how standards would be enforced or maintained. But, these common theme responses existed within agencies that both had stricter policies and those that had none.

Interestingly, of the two agencies that had the more stringent policies, though cost, training, and manpower were also mentioned, the agencies prioritized these resources to comply with policy. Taking a more holistic approach was also a factor for these agencies. As it pertains to their fitness policy, one stated that they had “to find a balance between stewardship to the taxpayer and providing our employees some opportunities to maintain and improve their health.” All agencies had on-site fitness facilities and equipment and/or community resources such as recreation centers, gyms, or fitness centers. See Table 3 for a summary of agency responses to these questions.

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76 Table 3
Agency Responses to Policy Rationale
Question Agency/Responses
What is the rationale behind
having/not having a fitness policy in
place, or for changing policy?
1 – the agency is in the process of reviewing and updating policies in order to apply best practices.

2 – case law, cost, manpower, buy in from administration, law suits

3 – physical fitness policy has never really been addressed

4 – the objective of the department is to develop and maintain a level of fitness in police personnel and to ensure their ability to accomplish assigned duties and provide satisfactory job performance without undue risk of injury or fatigue

5 – it was one of the Sheriff’s initiations in 2002

6 – to reduce long-term medical costs for employees, to improve employee wellness and productivity, to increase officer safety, and to increase the life span of officers/ employees

Who are involved decision makers
in fitness policy?
1 – Sheriff and Administrative Major who verifies policy changes to ensure it complies with law

2 – Sheriff, Chief Deputy, Director Personnel/Training

3 – Chief of Police and Executive Staff

4 – Chief of Police Bureau Commander, Training Division Commander and/or other departmental employees

5 – Sheriff and committee

6 – Chief of Police, Occupational Health staff, HR Director, City Manager, City Attorney

What factors determine or affect
fitness policy?
1 – resources, manpower, cost

2 – resources, manpower, cost

3 – time, money, effort, legality, injury, penalty for failure to maintain standards, resources, equipment

4 – finding a balance between stewardship to the taxpayer and providing employees some opportunities to maintain and improve their health

5 – we have the manpower, a more holistic approach was needed

6 – cost, provide training, build a gym/fitness center, staffing was not a major concern

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77 Rational choice theory assumes that individuals interact in a social process as part of decision-making, and in an organization, collective individual actions affect policymaking and input comes from both individual behavior and social interaction (Jones et al., 2006). It examines how individual choices interact with one another to produce outcomes, and how decisions are made by both considering the present and planning for the future (Green, 2002).

The above questions on the agency questionnaire were designed to test this theory to determine why specific policies were in place among a small sample of law enforcement agencies in North Carolina. The meaning of rational is applied to mean the most preferable and feasible alternatives available. One component of this theory holds that within a setting, decision makers will choose an alternative that benefits the most.

This assumes that first decision makers have ranked preferences for outcomes and possess the necessary information to optimize the preferred outcomes (Jones et al., 2006).

A closed-ended question on the questionnaire was asked of the agencies whether they were aware that North Carolina provides a full public health mandate that includes injury prevention. Only one responded yes. This agency had a more general wellness policy, but no specific fitness standards for officers. Two agencies responded no and three agencies did not answer definitively. Perhaps having knowledge or utilizing state resources available could assist agencies in this policy making process, but the question may have been vague or confusing, or maybe more detailed information should have been provided to the agency’s before asking this question.

Decisions are made to serve definite purposes and populations. Therefore, rationality is important in the decision-making process otherwise public utility can be

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78 adversely affected (Political Science Notes, 2013). With the responses given, it was not entirely clear on how agencies determined fitness policy. Perhaps questions should have delved into more detail as to how each factor was considered, rather than just listing what factors were considered in policy. However, in all cases more than one individual was involved in the discussion and input of policy (or policy change), therefore confirming that an interaction process took place with a decision being made as to the best choice for the agency with the resources and information present. It is more difficult to determine whether the utilitarian component outshined other options because of the limited information provided within question responses. So, to apply rational choice theory in general makes sense per the responses from agencies, but not enough is known as to why the utilitarian function of the theory explained fitness policy implementation.

Research Question 3
Research Question 3 attempted to find out whether data-driven results of injury or absenteeism are an agent or constraint as it pertains to fitness policy. One question on the agency questionnaire was asked as to whether policy intended to address work-related injuries and illnesses. Two agencies that had no fitness policy and one agency that did not have a policy but did have employee fitness incentives in place responded negatively to this question. The other three agencies that responded positively had some type of fitness policy in place, with policy ranging from more general to very specific standards.

Applying rational choice theory to these responses make sense as one element of the theory is constraints, or things/circumstances that exist, making a choice necessary.

Constraints also take into consideration the environment in which a choice was made (Green, 2002). Within each agency several factors as well as participants are involved in

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79 the decision-making process. Although ultimately it is the agency head who makes the final decision, there is no doubt that influences from others and the environment play a part. It is this interaction among human decision makers and individual choice that put policies into action (Jones et al, 2006).

Serving as constraints to agencies with no fitness policy seemed to be the common factors of cost, legal implications and manpower. These factors seemed to play a part in the policy decision-making process. Something that is not known is how much influence other individual(s) involved in the process had. It was not explored in the initial questioning but could have been valuable in addressing this particular research question.

For those agencies that had some type of fitness policy, common agents seemed to specify the necessity of officer health and safety, ensuring that officers could accomplish their duties. Wellness incentives in written policy emphasized the agency’s commitment to the well-being of officers so they could perform essential job tasks. Taking a holistic approach and finding balance between providing public services and providing for employees were common rationale. These agencies sought funds (either through city/county funds or grants) and provided training and facilities to ensure officer needs were met.

With the data that was collected and qualitatively analyzed, it is concluded that the null hypothesis be rejected, assuming that injuries and/or absenteeism rates are an agent of the current fitness policy. This was determined by examining the written policy of the agencies that had a current fitness policy in place. This analysis used several steps

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80 according to rational choice theory; identifying relevant agents and constraints, applying consistency, exploring predictions, and drawing conclusions (Green, 2002).

Threats to Internal Validity—Instrumentation
After conducting the analyses for this research, several observations must be mentioned as it pertains to the validity of the instruments used. The first instrument used, also serving as the independent variable was written agency fitness policy. The information was interpreted at its face value and believed to be represented and interpreted correctly in the study. However, for comparison purposes, I defined four categories in ranked order, from no policy present to the most stringent, mandatory policy. Perhaps another researcher would define or categorize policies differently for analysis purposes.

To control for any differences in policy change over the 5-year period, a binominal variable was created to simply represent that a fitness policy did change from year to year, or did not change from year to year. This again was a discretionary decision, and perhaps others would approach control in a different manner.

The use of OSHA mandated reported injuries and absences on the summary 300A form became questionable as to whether these records could be considered valid. For example, one agency reported employees having 164 days away from work (absenteeism), yet the next year, two days were reported and the year after that zero days were reported. So, whether the OSHA form was the most appropriate measure of injuries and absenteeism is questionable. Perhaps a better, more accurate and valid instrument might better have addressed the research questions, but this information was not initially known and so not observed until after data analyses. In addition, OSHA forms did not

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81 specify or differentiate officer injuries and absences from other agency employees such as nonsworn or civilian. One county agency even included all county employees in the summary form and did not distinguish between officer and other personnel.

The last instrument used was the agency questionnaire designed to test rational choice theory in the policy decision-making process at agencies. I designed the questionnaire, with input from a criminal justice advisory committee, made up of local criminal justice practitioners. Upon qualitative analysis of the data, it became evident that the questionnaires did not delve deep enough into the details of policy input, such as whether agency heads were pressured into having or not having a fitness policy, or if politics in any way played a role in this process. Therefore, one might argue that the questionnaire might pose internal validity threats.

When discussing validity in general, conclusion validity might be worth mentioning. This is essentially whether a relationship between variables is a reasonable one or not, given the data being studied. In this study, it is possible to conclude that, while an overall significant relationship seems to exist between policy and injury and absenteeism rates, the policy itself may not have caused the outcome. Perhaps some other factor(s), and not policy alone was responsible for the results of the study (Trochim, 2006).

Trustworthiness
On 09/01/16 Walden University IRB approved the proposed research study with the condition that each agency provide a signed letter or cooperation prior to data collection (Walden University IRB approval #09-01-16-0316158). Over a period of 5 months (October 2016 – March 2017), the six agencies that agreed to participate were

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82 approved by IRB as data collection sites. I covered all documentation and travel expenses related to the study as not to incur any cost to the agencies. After collecting all documents and speaking to the training officer at each agency, both a verbal and appreciation was voiced and a thank you card was sent to those involved in providing the data from each agency. The information was then reviewed and validated to verify and gain a better understanding of it. This helped to protect the integrity of the research.

A case study was selected for this research to gather some data about fitness policy and injury and absenteeism rates, as well as how policy is decided among a sample of law enforcement agencies in the Piedmont Triad area of North Carolina. Case study is designed to focus on the activities of organizations and to describe rather than generalize.

Therefore, transferability of the results outside of the study might be difficult to justify.

The collection of data for this study is assumed to be trustworthy as each instrument used (policy, OSHA forms and questionnaires) were reviewed with the training officer of the agency to ensure both the validity of data and to verify any oral and written communication recorded on the questionnaire through confirmability, or a reflective use of participant perspectives. This was used to build justification for themes (Creswell, 2013).

Through the presentation of this study’s purpose, data analyses, ethical considerations, and limitations discussion, it is hoped this research is viewed as both dependable and credible. Dependable in that an assessment of the integrated process of data collection, data analysis and theory generation were proposed and conducted; and credible in that every effort and intention was made to accurately interpret the data

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83 collected. All information was carefully documented and reported to provide the necessary details so similar future research might replicate the study if desired.

Summary
This chapter presented information on the recruitment process and instruments used to conduct the study pertaining to law enforcement fitness policies in relation to job injuries and absenteeism. Demographics on the six North Carolina law enforcement agencies in the sample were provided, as were the steps taken in the data collection process. Both qualitative and quantitative analyses were conducted to address the three research questions.

Agency fitness policies and OSHA 300A summary forms of six North Carolina midsized law enforcement agencies over a 5-year period were utilized in this multisite case study to determine whether a relationship existed between policy stringency and injury and absenteeism rates. Based on the quantitative analyses of ANOVA, Research Question 1 was addressed. A greater statistical significance was found between policy levels and injury rates than between policy level and absenteeism rates. When controlling for any change in policy from year to year, the opposite was found to be true.

Research Question 2 was analyzed qualitatively through responses on a questionnaire addressing policy decision-making factors and personnel. An agency’s training officer or designee provided the responses. Overall data from participant responses resulted in the emergence of common themes that were then applied to the utilitarian function within rational choice theory. Research Question 3 also utilized specific questionnaire responses and determined that injuries and/or absenteeism rates were an agent of current fitness policy.

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84 Chapter 5 interprets the findings and discusses the implications for social change.

It also makes recommendations for further research and provides a conclusion to this study.

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85 Chapter 5: Discussion, Conclusions, and Recommendations Introduction
The purpose of this mixed methods multisite case study was to determine whether fitness policy affected reported work-related injuries and absenteeism among a sample of six law enforcement agencies in the Piedmont Triad region of North Carolina, and to test the utility function component of rational choice theory to ascertain whether it explains fitness policy implementation. OSHA-reported injury and absenteeism data were used from years 2011-2015 to examine any effects that may have resulted in policy change.

Training officers were then asked about the policy decision-making process at each agency.

Interpretation of the Findings
A large amount of research has been conducted on the topics of law enforcement fitness for duty, as well as work-related injuries and absenteeism, both internationally and in the United States. However, a very limited amount of research has been conducted on agencies in North Carolina, and more particularly on midsize agencies across the state.

No similar academic research was found that had been conducted to examine OSHA- reported injuries and absenteeism in relation to fitness policy levels. The findings correlated with much of the existing literature addressing the role that fitness plays in injury prevention.

Three research questions guided this study and were designed to measure the effects of both fitness policy decision-making and work-related injury and absenteeism rates:

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86 1. What relationship, if any, exists between a North Carolina law enforcement agency’s fitness policy and work-related injuries and absenteeism?

2. When research emphasizes the benefits of maintaining a certain fitness level, particularly for first responders, does the utility function within rational choice theory explain why some North Carolina law enforcement agencies mandate physical fitness requirements for officers and others do not?

3. Are data-driven results on injury or absenteeism an agent or constraint as they pertain to the present fitness policy?
Research Question 1
To determine whether a relationship existed between a certain fitness policy level and injury and absenteeism rates, participating agencies were asked to provide a copy of their fitness policy for years 2011-2015 as well as a copy of their OSHA 300A summary form for the same 5-year period. For each of the 5 years, a fitness policy was placed in to one of four categories, creating the independent variable policy level. The levels included (in increasing order) those agencies with (1) no fitness policy, (2) a general/voluntary fitness policy, (3) annual in-service and mandatory fitness testing, and (4) biannual mandatory testing. If fitness policy changed from one year to the next, it was noted and used as a dummy control variable (policy change) to determine whether change in policy made a significant difference in injury or absenteeism rates. It was only noted whether there was no change in policy, or whether an increase in policy level took place. For injury and days missed from work, a standardized rate (per 100 employees) was calculated to allow for comparisons across different agency sizes.

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87 With SPSS, ANOVA was then applied using the F-test to evaluate whether group means within the dependent variable differed from each other among injury rates and absenteeism rates. It was found that ANOVA was significant between both policy level and injury rates, as well as policy level and absenteeism rates. The overall ANOVA was significant, and so follow-up tests were also conducted to evaluate pairwise differences among means. No significant difference was found between policy level and absenteeism rate, but a significant difference was found between policy level and injuries, with the agencies that required annual in-service and testing showing a greater decrease in injury rates when compared to agencies with other policies.

Theoretical Concepts
Rational choice theory (RCT) indicates that individual behavior and social interaction affect the policymaking process. This process begins with making choices; under rational choice theory, it is assumed that choices are made based on larger representative populations (Green, 2002). In RCT, rational is meant to reflect the most feasible and preferable alternative through utility maximization or the alternative that has the greatest benefit. The environment in which the choice is made contributes to the constraints or circumstances that exist, as decisions are not made in a vacuum. Then analysis examines how choices interact to produce outcomes (Green, 2002). Jones et al. (2006) contended that even though organizations make policy, the interaction of human decision makers along with individual choice is what puts policy into action because individuals want to maximize their preferences and self-interest. Decision makers hold ordered and ranked preferences for outcomes and possess the necessary information to connect choices to preferred outcomes. Therefore, the rationality component is important

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88 in decision-making; otherwise overall utility will be affected (Political Science Notes, 2013).

The next two research questions were designed to test RCT through qualitative analysis. A multisite case study was used because input from multiple agencies would provide more abundant insight about the decision-making process than input from one or few agencies. It also provided an opportunity to mine for common themes among responses. A questionnaire was designed to ask agency training officers about policy decision-making to determine if policy choice was indeed guided by RCT concepts. The questionnaire consisted of six main questions and four sub questions inquiring further into certain responses. Three of the questions were designed to address Research Question 2.

Research Question 2
To test whether the utility function within RCT explains policy decision-making, three questions were asked of agency training officers. The questions included inquiry about the rationale behind current policy, involved decision makers, and factors affecting policy. After a written record of the responses was received from each agency, member checking was conducted to verify response content. The narrative data were then analyzed, coded, and interpreted. Improving employee productivity and wellness, and increasing officer safety were common themes among agencies that had a fitness policy in place. Case law implications, cost, and lack of manpower and administrative support were common responses among those agencies without a fitness policy in place.

Responses to the question inquiring as to who was involved in the decision-making process included both internal as well as external agency employees, with all agreeing

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89 that the agency head had the final say. Common factors affecting fitness policy were cost and resources, similar factors found in the rationale behind current policy.

It could be argued that the responses represent RCT, in that both individual behavior and social interaction played a role in the policymaking process. Of those agencies including input from multiple individuals (both inside and outside the agency), choices were made based on the most feasible option that would have the most benefit (Green, 2002). Those providing input might include agency employees, the public, or both.

Research Question 3
To determine whether results of injury and absenteeism reports served as an agent or constraint to fitness policy, a closed-ended question was asked concerning whether the agency’s fitness policy was intended to address this issue. Then responses were compared to the factors given that contributed to current policy. At the agencies with fitness policies in place, policy was intended to address, at least partially, work-related injuries and absences. The agencies without fitness policies saw mainly the cost and resources to oversee such a policy as a constraint. Therefore, from the consistent information presented by agencies either having or not having policies, it was determined that an agent/constraint component of the RCT contributed to the overall decision- making process.

Existing Policies and Potential Approaches
North Carolina law enforcement agencies vary in fitness standards and policies.

Policies range from voluntary self-initiation to required fitness participation and testing.

Voluntary policies make it optional for officers to participate in fitness activities, either

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90 on their own time or through various agency-sponsored incentives. One example is an agency that provides officers an extended break time to exercise while on duty. Rather than a 30-minute lunch break, officers are allowed 60 minutes, if manpower and call volume allows. The department provides a fully equipped exercise room that is available 24 hours a day. This is a convenient incentive not only for police officers, but also for all agency employees.

Other agencies in the state require fitness training days, which might occur once, twice, or four times a year (for example) as part of an officer’s in-service training.

Requirements vary but may only necessitate that officers are present and participate in some way. Agencies that include mandated fitness policy ensure that facilities, consultation services, and appropriate resources are available to officers by offering various fitness and educational activities, or individual consultations if desired.

Limitations
Upon completion of this study, I found several limitations that must be disclosed.

These limitations included the instruments used, the geographical location selected, ecological fallacies, and sample size. Each is discussed in more detail below.

The instruments used consisted of both primary and secondary resources. The primary resource consisted of the questionnaire that was developed to specifically address policy decision-making at agencies. I validated the questionnaire by using feedback from a local advisory committee made up of local police practitioners, and reliability was assumed, as the same questionnaire was used for each agency. Yet upon qualitative analysis, it was discovered that more in-depth inquiries could have been used to delve deeper into how individual decisions were made or perhaps persuaded.

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91 Secondary data included written policy (if any) for an agency and OSHA 300A summary reports. It was learned that OSHA reporting varied. Not all agency forms distinguished injuries and absences by officers from those by nonsworn employees in the agency.

Accountability and methods of data collection were also questioned due to large variance in some of the data recorded from one year to the next.

Because data were collected from midsized law enforcement agencies in the Piedmont Trial Region of North Carolina, the results were limited. Only six of 11 agencies fitting the population criteria were selected for a more in-depth case study analysis. Therefore, statistical results cannot be generalized because of the small sample size. More specifically, the results are unique to this region and might differ from those of smaller, larger, rural, or more urban areas within the state or elsewhere.

Important to researchers is also being aware of potential ecological and individual fallacies (Frankfort-Nachmias & Nachmias, 2008). It should be noted that an agency not having or enforcing a fitness policy or standard does not imply that officers cannot or do not take individual responsibility for their own fitness. It also cannot be inferred that high absentee or injury rates reflect poor officer or agency performance, as absence or injury may not be caused by poor fitness levels. Absence is not just about a day away from work; it is tied to circumstances of an employee’s medical and personal life (Harte et al., 2011). Therefore, many factors must be considered when implementing a wellness or fitness program, given that multiple facets of life circumstances contribute to missing work for various reasons.

Findings in this study address the research questions in an effort to contribute to what little is known about the relationship between fitness policies and work-related

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92 injuries and absenteeism, specifically within law enforcement agencies in North Carolina.

Information was gained on how and why fitness policies are derived in some agencies, and suggestions derived from the study’s findings are made to promote positive social change.

Implications for Positive Social Change
This study has potential to contribute to positive social change at individual, community, and societal levels. The study’s most important implications relate to police officers’ role as public service responders. Though officers infrequently encounter situations that require them to meet physical demands, the inability to perform can have consequences for the individual officer, the agency, and the community (Means et al., 2011a). Study results suggest that some fitness standard is significantly related to lower injuries and fewer absences. The data should be encouraging to individuals and agencies alike that are seeking to promote the overall wellness and health of employees. More today than ever, organizations have to do more with less to maximize work output and increase productivity. This suggests that increasing productivity reduces organizational expense (Harte et al., 2011). According to the U.S. Department of Labor (n.d.), health improvement programs cost 0.5% of payroll, compared to 6.5% in combined costs related to replacement of workers, sick leave, short and long-term disability, and workers’ compensation. Employers are challenged by supporting employees’ needs (e.g., time off and health insurance) with cost-effective benefits that create a productive workforce.

Particularly when an administration aligns organizational goals and employee needs, employees’ productivity can be greatly influenced by their general health and well-being

330
93 (Harte et al., 2011). In this sense, the individual, agency, and taxpayers/recipients of public services all benefit.

Recommendations for Action
Investing in wellness programs that focus on preventing illness and maintaining health influences medical costs and absenteeism. Such programs can go a long way in helping to creative a high-performance environment, lower health care costs, and reduce absences (Harte et al., 2011). Funding for fitness programs could be included within agency budgets or agencies could seek state funding per North Carolina General Statute 130A-224 as it pertains to public health. This statute provides a full mandate for public health issues, including injury prevention (Stier et al., 2012). It is a collaboration worth exploring further. A partnership with the North Carolina Public Health Department would be advantageous to incorporating injury prevention programs. To justify continued funding, it would be necessary to routinely evaluate training methods (Ferguson et al., 2011). Evaluation results can be useful by also pointing out deficiencies or areas where improvements can be made. It is the obligation of criminal justice practitioners and researchers alike to render professional judgment to improve the well- being of those in the field (ACJS, n.d.). Poor health and fitness carry higher risks of injuries and absences, which in turn cost agencies and taxpayers more money. Therefore, to justify standards and funding, evaluation is a necessary component. Data collection that provides evidence-based results would help to justify the continuance (or elimination of) such programs in the future.

The main objectives of fitness policy include reducing the risks of both work- related injury and absenteeism (and therefore increasing the health benefits of officers)

331
94 and reducing agency and officer costs by way of fewer medical expenses and less absenteeism. The stipulation is that data should be collected and funding should be contingent upon evidence-based results. This could also be a beneficial form of accountability.

The purpose of providing alternatives is to offer optional approaches in case the initial, intended proposal does not completely work (Bardach, 2012) or needs to be adjusted in some way. The current interest lies in reducing workplace injuries and absences. Employers are aware that health and work are interrelated and that employers have a role in facilitating job retention and wellness (Irvine, 2011). Therefore, they are key players in policy change.

Recommendations for Further Study
The results of this study are limited to what was found among six law enforcement agencies within one region of North Carolina. The intent was to concentrate mainly on the patrol function within policing; however, with OSHA 300A summary statistics, it is difficult to do that. Therefore, it is suggested that actual OSHA 300 forms be analyzed to select out how injuries and absenteeism among patrol officers might differ compared to other sworn or nonsworn positions within an agency. This analysis would require more time and resources because those reported on the OSHA 300 form as injured or absent are listed by name; therefore, confidentiality would first have to be considered, and with the assistance of human resources a role distinction would have to be made among names as to pull out patrol officers. Alternatively, perhaps those patrol officers could be contacted and interviewed to determine whether the injury or absenteeism was indeed work-related.

332
95 It might also be interesting to compare differences in fitness levels and requirements for specialty teams (for example, SWAT, K-9) versus patrol as specialty teams generally require more strict fitness levels. Though the responsibilities differ, there may be a significant difference in injury and absenteeism rate when compared to patrol officers. Also, because more stringent requirements are often a condition of belonging to such specialty teams, how or why this policy was rationalized and decided might be explored to further test RCT or to test additional decision-making theories.

Conclusion
This study was conducted to address the gap in the literature regarding why police academy cadets have required fitness standards but not all law enforcement agencies require a maintained fitness level as a condition of employment in North Carolina. In the hiring process, a critical qualifying factor is the use of fitness testing; however, if testing is used agencies need to understand fitness assessments if they are to implement required standards (Cooper Institute, 2014). During this research, very limited studies were found specific to North Carolina agencies and fitness policy, and none were found that specifically examined OSHA-reported injuries and absenteeism compared to various agency fitness policies.

Providing quality public services to the community is demanding and often agency resources are stretched thin. Agencies are trying to find that delicate balance with limited resources, whether dollars, manpower, or time. Agencies discussed varying reasons for having or not having physical fitness policies in place, but regardless; all stressed the importance of officer safety which can be increased by paying attention to officer wellness (Office of Community Oriented Policing Services, 2015).

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96 Research continues to support the importance of a police officer’s physical and psychological health, but fitness is only one piece of a larger puzzle. Improving workplace productivity calls for a comprehensive strategy that includes integrating evidence-based measurement because it is important to show that the health and productivity of the workforce directly relates to the health and well-being of the organization (Harte et al., 2011; Office of Community Oriented Policing Services, 2015).

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policies/practices. Retrieved from http://www.eeoc.gov/laws/practices/

van Dongen, J. M., Proper, K. I., van Wier, M. F., van der Beek, A. J., Bongers, P. M.,

van Mechelen, W., & van Tulder, M. W. (2011). Systematic review on the

347
110

financial return of worksite health promotion programmes aimed at improving

nutrition and/or increasing physical activity. Obesity Reviews, 12(12), 1031-1049.

doi:10.1111/j.1467-789X.2011.00925.x

Violanti, J. M., Fededulegn, D., Andrew, M. E., Charles, L. E., Hartley, T. A., Vila, B., &

Burchfiel, C. M. (2013). Shiftwork and long-term injury among police officers.

Scandinavian Journal of Work, Environment & Health, 39(4), 361-368.

doi:10.5271/sjweh.3342

Vogt, W. P., & Johnson, R. B. (2011). Dictionary of statistics & methodology: A

nontechnical guide for the social sciences (4th ed.). Los Angeles, CA: SAGE.

Walden University. (2010). Institutional review board for ethical standards in research.

Retrieved from http://researchcenter.waldenu.edu/Office-of-Research-Integrity-

and-Compliance.htm

Williams, B. (2002). Fitness in law enforcement. Pittsfield Township Police

Department. Eastern Michigan University. Retrieved from

http://www.emich.edu/cerns/downloads/papers/PoliceStaff/Shift%20Work,%20%

20Stress,%20%20Wellness/Fitness%20in%20Law%20Enforcement.pdf

Wirtz, A., & Nachreiner, F. (2012). Effects of lifetime exposure to shiftwork on fitness

for duty in police officers. Chronobiology International, 29(5), 595-600.

doi:10.3109/07420528.2012.675844

Wright, B. R., Barbosa-Leiker, C., & Hoekstra, T. (2011). Law enforcement officer

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111

Zagaria, P. (2007, August 23). Fitness training for law enforcement. PoliceOne.com.

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/1340939-Fitness-training-for-law-enforcement/

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349
112

Appendix A: North Carolina Regions

Reference: Piedmont Triad Council. (2012). Retrieved from http://www.ptrc.org/

350
113

Appendix B: Piedmont Triad Region Law Enforcement Agencies

Agency Population 50,0000 – 500,000
Alamance County yes
-City of Burlington yes
Caswell County no
Davidson County yes
Davie County no
Forsyth County yes
-City of Winston-Salem yes
Guilford County yes
-City of Greensboro yes
-City of High Point yes
Montgomery County no
Randolph County yes
Rockingham County yes
Stokes County no
Surry County yes
Yadkin County no

351
114

Appendix C: Population of Midsize Law Enforcement Agencies in the Piedmont Triad Region of North Carolina

Agency 2010 census population
Alamance County Sheriff’s Office 151,131
Burlington Police Department 49,963
Davidson County Sheriff’s Office 162,878
Forsyth County Sheriff’s Office 350,670
Winston-Salem Police Department 229,617
Guilford County Sheriff’s Office 488,406
Greensboro Police Department 269,666
High Point Police Department 104,371
Randolph County Sheriff’s Office 141,752
Rockingham County Sheriff’s Office 93,643
Surry County Sheriff’s Office 73,673
Note. From “2010 Census Interactive Population Search,” by U.S. Census Bureau, n.d. (https://census.gov/). N = 11. Midsize = areas with 50,000-500,000 population.

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115

Appendix D: Sample Agency Fitness Policy

7.4.1 OBJECTIVE
The objective of the xxxxxxx Police Department is to develop and maintain a level of fitness in police personnel and to ensure their ability to accomplish assigned duties and provide satisfactory job performance without undue risk of injury or fatigue.

7.4.2 RESPONSIBILITIES
The Training Division is primarily responsible for the coordination and execution of all tasks pertaining to departmental directive 8.1.3.

7.4.3 COMPONENTS
The fitness services, provided at no charge by the department, includes:

1. An optional nutritional assessment. Officers complete a journal about their present health/eating habits.

2. A physical fitness assessment. The assessment consists of the following:
 Age, Height measurement, Weight measurement
 Body composition (Body Fat Percentage) – is measured by using skin fold calipers.  Blood pressure and heart rate - are measured by a sphygmomanometer.  Aerobic fitness - is measured by both a 1.5 mile walk/run and a 300-meter walk/run.  Strength fitness - is measured by:
 Maximum one-time bench press
 Maximum number of push-ups within one-minute
 Maximum number of sit-ups within one-minute
Once all tests are computed, each participant is categorized into one of five levels of fitness (age adjusted):
1) Very Poor 2) Poor 3) Fair 4) Good 5) Excellent 6) Superior Each participant receives a synopsis of his/her results.

7.4.4 ANALYSIS OF RESULTS
Each officer will be given a copy of their physical assessment synopsis if requested. They may at any time schedule an appointment with the appropriate training coordinator for a free consultation concerning their results.

7.4.5 DUTIES
The Training Division will ensure that staff members performing tasks assessments are capable of properly conducting physical fitness assessments, providing fitness counseling and providing a written printout of results on each participant. Testing will be conducted at the Public Safety Training Facility utilizing Departmental equipment.

Retesting – Any participant can be retested upon request of the participant. Portions of any segment or the entire program can be retested.

7.4.6 FILE MAINTAINANCE
Any information obtained which pertains to the health and wellness program will be maintained in the Training Division and monitored by the appropriate training coordinator.

STANDARD OPERATING PROCEDURE UNIT: Training Division
SUBJECT: HEALTH AND FITNESS OF SWORN

OFFICERS
NUMBER 7.4
EFFECTIVE DATE: 8/1/04 PAGE 1 OF 1
REVISION HISTORY: (Adopted 1/1/96) R1-7/1/99 R2 8/1/04 R3 8/10/07 R4 3.6.09 R5 10.14.13

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116

Appendix E: OSHA 300A Form

354
117

Appendix F: Participating Agency OSHA-Reported Injuries in Order of Fitness Policy Stringency

Agency Year # of
employees
Days away
from work
*Absent rate
(per 100)
Total
injuries
*Injury rate
(per 100)
(1) 2011 228 2 .88 12 5.26
2012 248 117 47.18 15 6.05
2013 254 154 60.63 10 3.94
2014 254 0 0.00 14 5.51
2015 262 12 4.58 12 4.58
(2) 2011 missing 55 missing 23 missing
2012 1206 248 20.56 61 5.16
2013 892 411 46.08 65 7.29
2014 1023 305 29.81 79 7.72
2015 954 389 40.78 66 6.92
(3) 2011 248 138 55.65 31 12.50
2012 261 191 73.18 38 14.56
2013 268 19 7.09 30 11.19
2014 266 75 28.20 12 4.51
2015 279 43 15.41 18 6.45
(4) 2011 901 426 47.28 66 7.33
2012 900 128 14.22 66 7.33
2013 929 471 50.70 65 7.00
2014 881 363 41.20 56 6.36
2015 881 266 30.19 38 4.31
(5) 2011 230 3 1.30 8 3.48
2012 238 164 68.71 12 5.04
2013 240 2 .83 8 3.33
2014 243 0 0.00 2 .82
2015 235 18 7.66 7 2.98
(6) 2011 164 15 9.15 17 10.37
2012 182 5 2.75 18 9.89
2013 171 25 14.62 15 8.77
2014 172 52 30.23 17 9.88
2015 171 267 156.14 20 11.70

* Absenteeism/injury rate is total number of days away from work (or total number of injuries) divided by total number of employees times 100 (rounded to nearest hundredth)

355
118

Appendix G: Agency Questionnaire
Agency:

# of sworn officers:

Title:

Does your agency have a physical fitness policy? (please include copies of years 2011- 2015)

If YES

is it mandatory or voluntary?

how long has the policy been in place?

What is the rationale behind having/not having a fitness policy in place, or for changing policy?

Who are involved decision makers in fitness policy? Who ultimately decides?

What factors determine or affect fitness policy? (ie: resources, manpower, cost, etc.)

Was policy intended to address work-related injuries and illnesses?

Are you aware that North Carolina provides a full public health mandate that includes injury prevention?

If no, would you want more information?

If yes, is that part of the rationale for having/not having a fitness policy?

356
R E S E A R C H Open Access
Accuracy of peak VO2 assessments in career
firefighters
Dana C Drew-Nord 1*, Jonathan Myers 2, Stephen R Nord 3, Roberta K Oka 4, OiSaeng Hong 1 and Erika S Froelicher 5 Abstract
Background: Sudden cardiac death is the leading cause of on-duty death in United States firefighters. Accurately assessing cardiopulmonary capacity is critical to preventing, or reducing, cardiovascular events in this population.

Methods: A total of 83 male firefighters performed Wellness-Fitness Initiative (WFI) maximal exercise treadmill tests and direct peak VO 2 assessments to volitional fatigue. Of the 83, 63 completed WFI sub-maximal exercise treadmill tests for comparison to directly measured peak VO 2 and historical estimations.

Results: Maximal heart rates were overestimated by the traditional 220-age equation by about 5 beats per minute (p < .001). Peak VO 2 was overestimated by the WFI maximal exercise treadmill and the historical WFI sub-maximal estimation by ~ 1MET and ~ 2 METs, respectively (p < 0.001). The revised 2008 WFI sub-maximal treadmill estimation was found to accurately estimate peak VO 2 when compared to directly measured peak VO 2.

Conclusion: Accurate assessment of cardiopulmonary capacity is critical in determining appropriate duty assignments, and identification of potential cardiovascular problems, for firefighters. Estimation of cardiopulmonary fitness improves using the revised 2008 WFI sub-maximal equation.

Background
Every 23 seconds a fire in the United States requires the services of a career or volunteer fire department [1].

Sudden cardiac death is the most common cause of on-
duty death among firefighters and occurs at higher rates than those found in similar occupations, such as police and emergency medical services [2].

A joint task force of the International Association of
Firefighters (IAFF) and International Association of Fire Chiefs developed the Fire Service Joint Labor Manage-
ment Wellness-Fitness Initiative (WFI) in 1997. Revi-
sions in the 1999 and 2008 WFI recognize the
firefighter as the “most important asset ” i nt h ef i r es e r - vice, and its intent is to improve firefighter function, on- duty effectiveness, and overall quality of life, while redu- cing morbidity and mortality r elated to fire fighting [3].

A major component of the WFI is assessment of fire-
fighters ’ cardiopulmonary capacity, with a stepmill test, sub-maximal, or a maximal exercise treadmill test. The
WFI mandates that firefighters have a maximal exercise
test at age 40 and every other year thereafter. The maxi- mal exercise test is intended to measure peak VO
2 (measured as ml/kg -1·min-1), which is an objective, clini- cal measure that defines the limits of cardiopulmonary
function. Peak VO
2 reflects an individual ’sa b i l i t yt o
increase their heart rate and stroke volume, and redirect oxygenated blood to muscles for work on demand. Exer-
cising at levels beyond which the cardiopulmonary sys-
tem can adequately supply oxygen (commonly termed
the anaerobic or ventilatory threshold, or VT) involves progressively greater degrees of oxygen-independent
muscle metabolism, which is dramatically less efficient than aerobic metabolism, and can compromise cardio-
vascular function [4].

Quantifying the energy demands of firefighting during
fire suppression is difficult due to the inherent dangers of fire suppression tasks. Most efforts to define the
arduous physical work demand requirements during
firefighting have been focu sed on establishing the level of metabolic equivalents (METs) (1 MET ≈ 3.5 ml of
O
2/kg/min) using simulated tasks. A MET is a multiple
of the resting metabolic rate and is commonly estimated using standardized equations [4]. 10 METs is roughly
equivalent to jogging a 10-minute mile; 14 METs is
* Correspondence: [email protected]
1Department of Community Health Systems, School of Nursing, University of California, 2 Koret Way, San Francisco, California 94143, USA Full list of author information is available at the end of the article Drew-Nord et al . Journal of Occupational Medicine and Toxicology 2011, 6:25 http://www.occup-med.com/content/6/1/25
© 2011 Drew-Nord et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

357
similar to many extended competitive activities such as running or rowing competitively, or bicycle racing at a high level [5]. The estimated METs proposed for fire-
fighting range from 9.6 [6] to 14 [7] (a peak VO
2 range
of 33.6 ml/kg -1 min-1·to 49 ml/kg -1·min-1). Recent analy- sis of physical aptitude tests a mong firefighter recruits demonstrated that male recruits ’ average VO 2 require- ment was 38.5 ml/kg -1·min-1 (11 METs) to complete a
timed simulated firefighting assessment course [8]. Mea- surement of functional capacity in 23 firefighters sug- gested that a mean of 41.54 ml/kg
-1·min-1 (11.9 METs)
is required to complete stan dard fire suppression tasks while wearing personal protective equipment [9].

Firefighting work demands can be extreme and accu-
rate assessment of cardiopulmonary status, as well as
detection and treatment of any underlying cardiovascu-
lar disease, is critical to insure firefighter fitness for duty and prevent on-duty cardiac events or death. The 1999
WFI sub-maximal exercise te st was found to overesti-
mate true peak VO
2 in individual firefighters [10]. Con-
cern about overestimation led to a revised equation for estimating peak VO
2 from sub-maximal exercise tread-
mill tests in the 2008 WFI.

Materials and methods
Given that previous sub-maximal exercise test results in the WFI were shown to overestimate peak VO
2,a n dt h a t
the WFI maximal exercise t readmill protocol has not
been validated for accuracy in the literature, this study was undertaken to assess the validity of both the maximal and revised sub-maximal exercise treadmill peak VO 2
estimates in firefighters. Specifically, the present study tested the following comparisons: (a) estimated maximal heart rate (220 - age) to actual measured maximal heart rate; (b) WFI maximal exercise estimated peak VO
2 to
directly measured peak VO 2;c )a v e r a g e dp r e - r e v i s i o n sub-maximal estimated peak VO 2 to revised sub-maximal
estimated peak VO 2; and (d) directly measured peak VO 2 to revised WFI sub-maximal estimated peak VO 2.

Study Setting and Participants
The study setting was a medium-sized suburban fire
department in the eastern region of the San Francisco
Bay Area in northern California. This department serves approximately 163,000 citizens and covers 46 square
miles. All firefighters (N =1 0 5 )a s s i g n e dt os u p p r e s s i o n duties were recruited, including firefighters, firefighter/ paramedics, firefighter/engineers, firefighter/captains and battalion chiefs. There were no women suppression fire- fighters in the department studied. This is consistent
with national career firefighter statistics as women only represent approximately 4.5% of the fire service [11]. All testing took place during a five-week period between
December 2008 and January 2009.

Inclusion criteria for participation required that each participant had successfully completed a WFI examina-
tion within the previous nine months and achieved a
minimum of 10 METs (peak VO
2 of 35 ml/kg/min), on
either a sub-maximal (using the pre-2008 equation), or
maximal exercise treadmill test. Exclusion criteria
included injury, illness, or scheduling conflicts that pre- cluded testing during the study period. The final study population consisted of 83 male career firefighters from all suppression ranks in this department.

The study was conducted with approval of the Univer-
sity of California San Francisco Committee on Human
Research. Signed informed consents were obtained and
all testing was conducted during on-duty hours with the approval of the department and union local.

Testing occurred at an occupational health clinic
where previous WFI examinations for this fire depart-
ment had been conducted. A physician board certified
in internal medicine and occ upational medicine, and a
nurse practitioner experienc ed in exercise testing, per- formed all treadmills and direct VO
2 measurements.

Participants arrived on the day of scheduled testing with their assigned duty crew, with gym clothes and running
shoes appropriate for completing a maximal exercise
test.

Measurements
Data collection consisted of medical record abstraction for demographics, cardiovascular risk factors and exer- cise test information. Demographic characteristics
included age, rank, and years o f fire service. Definitions of cardiovascular risk factors were obtained from the
American Heart Association, Adult Treatment Panel III
(ATP III), The Seventh Report of the Joint National
Committee on Prevention, Detection, Evaluation and
Treatment of High Blood Pressure (JNC7), and the Cen-
ters for Disease Control and Prevention [12-15]. All
serum samples were analyzed at the same hospital-based
certified laboratory (Centers for Medicare and Medicaid Services Clinical Laboratory Improvements Amend-
ments (CLIA)). Cardiovascular risk factors of the partici- pants are summarized in Table 1.

Maximal Heart Rates
Maximal estimated heart rates were calculated as 220-
age. Directly measured maxi mal heart rates were deter- m i n e df r o mt h ee l e c t r o c a r d i o g r a ma tt h ep o i n to fv o l i - tional fatigue as determi ned by the firefighter and
corroborated by the direct VO
2 assessment indicating
that they had crossed the VT.

Maximal Exercise Treadmill with Direct Peak VO 2
Assessment
All 83 participants completed a maximal exercise test
using the 2008 WFI Protocol with concurrent direct
peak VO
2 measurements. Maximal exercise treadmill
Drew-Nord et al . Journal of Occupational Medicine and Toxicology 2011, 6:25 http://www.occup-med.com/content/6/1/25

358
tests were considered complete when the firefighter
indicated volitional fatigue ( n = 83, see above), or if ter- minated by the testing physician due to concerns about
cardiopulmonary distress ( n = 0). The WFI protocol is a modified ramp protocol comprised of a 3-minute warm-
up period at 3 mph - 0% grade, followed by fifteen 1-
minute stages. Stage 1 begins at 4.5 mph and 0% grade,
with the treadmill incline increasing 2% and speed
increasing by 0.5 mph alternately in stages 2 through

15. The WFI maximal exercise treadmill estimates peak
VO
2 based on the American College of Sports Medicine
metabolic equation for running [16].

Peak VO 2 was obtained using the Cardio Coach
CO2™ VO2 Fitness Assessment System, Model 9001-
RMR (Korr Medical Technologies, Salt Lake City,
Utah). The Cardio Coach CO
2™ is an economical,
portable metabolic testing device that is feasible for
use in a clinic and has been previously validated for
measurement of peak VO
2 levels [17,18]. The Cardio
Coach CO 2
TM is a dual gas analyzer (O 2 and CO 2)t h a t
automatically calibrates to standard temperature and
pressure, dry at the beginning of each testing cycle.

The Cardio Coach CO
2™ measures heart rate using
the Polar T-31 heart monitor (Polar, Inc., Lake Suc-
cess, NY). Heart rate and VO
2 (ml/kg -1·m i n-1), VCO 2
(ml/kg -1 ·m i n -1 ), VE/VO 2, VE/VCO 2,V Ei nL / m i n , FeO 2%, Fe CO 2%, and respiratory exchange ratio are
graphically reported every 15 seconds. The Cardio
Coach CO 2™ uses the ventilatory equivalents method
(Ve/VO 2) to detect VT (Korr Medical Technologies,
2009).

Revised Sub-maximal Exercise Treadmill Assessments
In the latter part of 2008, the WFI introduced a revised equation for estimating peak VO 2:p e a kV O2 = 56.981 + (1.242 × TT) - (0.805 × BMI), where TT is the test time required to achieve target heart rate, and BMI is Body
Mass Index. The 2008 WFI calculates target sub-maxi-
mal heart rate (208 - (0.7 × age) × 0.85, whereas pre-
vious sub-maximal heart rates were based on (220-age)
× 0.85 [3,19].

Of the 83 firefighters who volunteered for the maxi-
mal exercise treadmill tests and directly measured peak VO
2, 63 subsequently completely their annually sched-
uled WFI examination, which included a sub-maximal
exercise treadmill test, within the subsequent four to
eight weeks. These subsequent WFI sub-maximal exer-
cise treadmill tests, using t he revised equation, took place under identical conditions as the study WFI maxi- mal exercise treadmill tests but without the direct VO
2 measurement. The sub-maximal test uses the WFI
treadmill protocol (see above) but terminates 15 seconds after the firefighter reaches their target heart rate.

Pre-revision Sub-maximal Exercise Treadmill Assessments Prior to the 2008 WFI revision there was no published
equation for the estimation of peak VO 2 from the sub-
maximal exercise treadmill. The estimated peak VO 2
was determined by duration of the test and stage
achieved [19]. Between one and seven historical sub-
maximal test results were available for each of the 63
participants, and were averaged to create comparative
historical variables.

Procedure
Participant ’s height, weight and resting blood pressure was measured. A resting electrocardiogram (ECG) was
completed, using the Welch-Allyn Schiller AT-10 6-
Channel electrocardiograph/treadmill (San Diego, Cali-
fornia). Upon completion of the resting ECG the Mason-
Likar lead configuration was modified to accommodate
the exercise treadmill [4]. The participant was then fitted with the appropriate 2-way non-rebreathable mask
(Hans-Rudolph, Inc., Shawnee, Kansas). The mask com-
pletely covered the nose and mouth of the participant
and was checked for air leaks to eliminate extraneous
room air from affecting the interpretation of peak VO

2. A standing electrocardiogram was obtained and the
treadmill was initiated. At test termination the firefighter recovered in the supine position. Available data from the maximal exercise treadmills is detailed in Table 2.

Statistical Analyses
Prior to all analysis all data were examined using stem and leaf plots and found to have normal distribution.

Table 1 Participant Cardiovascular Risk Factor Profile - Maximal Exercise Treadmill-Peak VO 2 Assessment (n = 83) Risk Factor Mean, SD
Body Mass Index (kg/m 2) 28.2 (± 3.9)
Systolic BP 117 (± 10)
Diastolic BP 69 (± 7)
Total Cholesterol* (mg/dL) 197 (± 38)
HDL** (mg/dL) 47 (± 11)
LDL** (mg/dL) 126 (± 36)
Cholesterol/HDL Ratio 4.35 (± 1.17)
Triglycerides (mg/dL) 118 (± 70)
*-fasting
**- HDL - high density lipoprotein; LDL - low density lipoprotein Table 2 Maximal Exercise Treadmill Data (n = 83)
Minimum Maximum Mean, SD
Resting Systolic 102 164 122 (±10)
Resting Diastolic 60 100 73 (±8)
Resting Heart Rate 42 91 63 (±10)
Maximal Heart Rate 130 194 174 (±10)
Peak VO 2 Actual 26.3 69.5 43.6 (±9.1)
RER* - Peak Exercise 0.90 1.28 1.09 (± .07)
* - Respiratory Exchange Ratio
Drew-Nord et al . Journal of Occupational Medicine and Toxicology 2011, 6:25 http://www.occup-med.com/content/6/1/25

359
Dependent t-tests were conducted on all 83 participants to test for differences between:
1) Estimated maximal heart rate (220 - age) and
directly measured maximal heart rate.
2) WFI maximal exercise treadmill estimated peak
VO
2 and directly measured peak VO 2.

Additional dependent t-tests were conducted on the
results of the 63 participants who subsequently per-
formed a revised WFI sub-maximal exercise treadmill
test for differences between:
1) Averaged pre-revision WFI sub-maximal exercise
treadmill estimated peak VO
2 mean (converted to
METs) to revised WFI sub-maximal exercise tread-
mill estimated peak VO 2 (converted to METs).
2) Directly measured peak VO 2 (converted to METs)
to revised WFI sub-maximal exercise treadmill esti-
mated peak VO
2 (converted to METs).

All dependent t-tests were two tailed, with a =0 . 0 5
used for statistical significan ce. Statistical analyses were performed using SPSS Version 15.0 (SPSS, Inc., Chicago, Illinois).

Results
There were 105 active suppression male career firefigh- ters eligible for participation in the study. Of those, five were new hires who had not completed a WFI examina-
tion. Six firefighters chose not to participate; of the 94 choosing to participate 11 could not be scheduled for
maximal exercise tests due to injury, illness or schedul- ing conflicts resulting in an n =8 3f o rt h i ss t u d y .T h e participants ’ ages ranged from 26 to 57 years with a
mean of 41.1; 94% of the participants were Caucasian,
and 6% were Hispanic or African-American. The years
of firefighting ranged from 2 to 34 with a mean of 15.6.

Maximal Estimates and Measurements
The traditional maximal heart rate estimation (220 -
age) was significantly higher than measured maximal
heart rate (178.6 vs. 173.6 with a mean difference of

4.96 beats/min, p < 0.001, 95% CI: 3.03, 6.90). Estimated peak VO
2 was significantly higher than directly mea-
sured peak VO 2 (47.7 vs. 43.6, with a mean difference of

4.06 ml/kg/min, (1.16 METs) p < 0.001, 95% CI: 2.88,

5.23).

Sub-maximal Estimates and Measurements
Within four to eight weeks of the maximal exercise
treadmill tests 63 participants completed a sub-maximal exercise treadmill test (using the revised 2008 WFI
equation). Their average age was 40.19 years (± 6.9) and average years of firefighting was 14.4 (± 6.8). All firefigh- ter suppression ranks were represented in this sub-
group. The subsequent examination allowed for compar-
ison of the revised sub-maximal exercise treadmill peak VO
2 estimate to an averaged pre-revision (comparative
historical variable) sub-max imal exercise treadmill peak VO2 estimate and the recently obtained directly mea-
sured peak VO 2. For simplicity in reporting sub-maxi-
mal results all peak VO 2 results were converted to
METs (peak VO 2/3.5).

A statistically significant difference was found between pre-revision sub maximal exercise treadmill peak METs
mean estimates and revised sub-maximal peak METs
estimates (14.81 vs. 12.58, with a mean difference of

2.23 METs, p < 0.001, 95% CI: 1.86, 2.59) These findings support previous research determining that WFI sub-
maximal peak METs estimates prior to the 2008 revi-
sion were overestimated [10]. Revised sub-maximal
treadmill METs estimates did not differ from directly
measured maximal exercise treadmill METs, indicating
that the revised 2008 estimating equation is a reasonable estimate of METs (12.64 vs. 12.58 with a mean differ-
ence of .07 METs, p ≤ .76, 95% CI: -.39, .54) This repre- sents additional validation of the accuracy of the new
estimating equation [3]. All maximal and sub-maximal
comparisons are summarized in Table 3.

Discussion
Fire departments often struggle to determine fitness for duty for their members who return from an injury or ill- ness, prepare to embark on wildland strike teams, heavy rescue missions, or for daily work assignments. There
are ongoing efforts to define minimally acceptable and
safe fitness levels; levels that should be informed by the energy requirements needed during a firefighter ’st o u r of duty. Maximum directly measured METs for the fire-
fighters in this study ranged from 7.5 to 19.9, indicating that some participants might have a difficult time meet- ing the demands of the job while others appear ade-
quately fit. Four different methods of cardiopulmonary
assessment are compared here: direct measurement of
peak VO
2, estimated peak VO 2 derived from a maximal
exercise treadmill equation, historical average of pre- revision estimated peak VO
2 sub-maximal exercise
treadmills, and estimated peak VO 2 derived from the
revised (2008) sub-maximal exercise treadmill equation.

Directly measured peak VO 2 is the most objective and
considered the “gold standard ” of the four methods [4].

The difference observed in maximum heart rate
between directly measured maximum heart rate (while
wearing a non-rebreathable mask), and a 220-age esti-
mated maximum heart rate (part of the maximal exer-
cise treadmill estimation equation) provides some
explanation for the over-estimation. Estimated maximal
Drew-Nord et al . Journal of Occupational Medicine and Toxicology 2011, 6:25 http://www.occup-med.com/content/6/1/25

360
heart rates were about 5 beats per minute higher than
those measured during peak exercise. Heart rates are a
method used on the fire ground to evaluate a firefigh-
ters ’ capability to re-enter the fire scene. Using target heart rates that exceed true maximums, or percentages
of estimated maximum heart rates that are inaccurate,
could result in dangerous duty assignments.

Assessment of direct peak VO
2 and maximal exercise
treadmill results indicate that the equation utilized by the WFI maximal treadmill over-estimates peak VO 2 by
an average of 4.06 ml/kg -1 ·min -1, or approximately 1 MET. If a firefighter’ s fitness level is less than optimal, or if they have underlying cardiovascular disease, this overestimation could lead to on-duty clearances that
could prove compromising.

Revised sub-maximal exercise treadmill peak VO2
estimates were compared to averaged pre-revision his-
torical sub-maximal exercise peak VO
2 estimates. The
average overestimation o f the historical mean was
approximately 2 METs. This finding supports the Mier
a n dG i b s o nr e p o r t( 2 0 0 4 )t h a tt h ep r e - r e v i s i o nW F I sub-maximal treadmill equation overestimated peak
VO
2, and that those equation results should be used
with caution for duty assignment decisions.

The comparison of directly measured peak VO 2 to the
revised sub-maximal exercise treadmill peak VO 2 esti-
mates (n = 63) found that there were no differences
between the two assessment methods. When comparing
revised WFI sub-maximal e xercise treadmill peak VO 2
estimates to previous years of testing, or to reports in the literature, careful consideration must be given to
which estimation method was used. The same task,
measured with different estimating equations, can result in different results as demonstrated herein.

Limitations and Strengths
The limitations of our study include the self-selection bias of the participants, the limited gender and ethnic demographics of the group (all male, predominantly Cau- casian), and the range in number of historical sub-
maximal exercise treadmill VO 2 estimates, resulting in a less than ideal comparison group. While testing was
completed within a four month period, it included the
winter holiday season which may have had a seasonal
influence on fitness behavior (resulting in an increase or decrease in exercise intensity). The composition of the sample is reflective of the department in terms of gender and ethnicity. There is an average four to eight week gap between the direct measure peak VO
2 and the sub-maxi-
mal exercise treadmill peak VO 2 assessment without any documentation of fitness behaviors. However, any fitness improvement on the part of firefighters in the interim
would have directed the results towards the null.

The strengths of our study include the number of parti- cipants, their range in age, rank, firefighting experience, and their experience with the WFI protocol. The avail-
ability of seven years historical data can be viewed as a strength. Use of the mask to measure peak VO
2 was
familiar to the participants as they routinely work with self-contained breathing a pparatus. The ability to per- form all testing components while on duty encouraged
participation. There were no incentives offered for parti- cipation. All testing was completed in the same facility using the same equipment and personnel, thus increasing consistency of testing and inter-rater reliability.

Clinical Implications
Firefighters who have been tested using earlier estimation equations may require careful explanation as to a notice- able drop in test results when using the revised 2008 WFI equation. Participants are likely to be disappointed to see a reduction in their “fitness level” when they have not chan- ged their patterns, nor workout habits, between testing cycles. Again, if a fire fighter falls into the lower fitness categories, or has underlying cardiovascular disease, inac- curate estimates could contribute to cardiac compromise.

Conclusions
In order to protect firefighters from potentially life- threatening cardiac situations it is imperative that
Table 3 Comparisons: Heart Rate, Peak VO 2, Estimated METs n Mean SD SEM 95% CI Lower 95% CI Upper t d Sig(2-tailed) Estimated Max.

HR: Actual Max. 83 4.96 8.87 .97 3.03 6.9 5.09 82 .00
HR
Estimated peak
VO
2: Direct
measure peak VO 2
83 4.06 5.39 .59 2.88 5.23 6.85 82 .00
Pre-revision METs
Est.: Revised METs estimate 63 2.23 1.46 .18 1.86 2.59 12.14 62 .00 Direct METs:

Revised Sub-maximal METs estimate 63 .07 1.85 .23 -.39 .54 .31 62 .76 Drew-Nord et al . Journal of Occupational Medicine and Toxicology 2011, 6:25 http://www.occup-med.com/content/6/1/25

361
exercise testing results are accurate, whether the test is being used for duty assignment or part of a comprehen-
sive risk assessment. The results from the revised sub- maximal exercise treadmill estimation equation appear
to accurately reflect directly measured peak VO
2 results.

WFI maximal treadmill peak VO 2 estimates should be
interpreted with caution, especially as they appear to
o v e r - e s t i m a t eM E T sb ya na v e r a g eo f1 .G i v e nt h e potential for over-estimatio no ff i t n e s s ,p r o v i d e r sw h o make fitness-for-duty asse ssments should consider the
energy requirements of the job, any underlying cardio-
vascular risk factors, and the method of testing used
when recommending return to, or continuation of,
duties. These findings support the continuation and
further expansion of reliable exercise testing of firefigh- ters, within the context of a cardiovascular disease pre- vention program such as the WFI.

Performing measured peak VO
2 and maximal exercise
treadmill tests can be challenging for fire departments to accomplish due to limited resources. The 2008 WFI
sub-maximal exercise treadmill test can be safely admi- nistered outside of a medical setting using tools that are often available within the fire department (treadmill,
stopwatch, and Polar heart m onitor). Disadvantages of
the sub-maximal treadmill test are the limited means for assessing underlying cardiovascular conditions, and the inability to determine maximal cardiovascular perfor-
mance directly. However, the revised 2008 sub-maximal
treadmill peak VO
2 estimation equation is a valid tool
to assess interim progress in cardiovascular training
programs.

Acknowledgements
The corresponding author would like to thank the Livermore-Pleasanton Fire Department administration, suppression, and support staff for their trust, enthusiasm, and participation in this project; the National Institute for Occupational Safety and Health (Grant #T42 OH 008429) for its traineeship support; and the UCSF School of Nursing Century Club for its financial support.

Author details
1Department of Community Health Systems, School of Nursing, University of California, 2 Koret Way, San Francisco, California 94143, USA. 2School of Medicine, Stanford University, Palo Alto VA Health Care System, 3801 Miranda Avenue, Palo Alto, California 94304-1290, USA. 3Premier COMP Medical Group, Inc. 5635 W. Las Positas Blvd., Suite 401, Pleasanton, CA 94588, USA. 4Palo Alto VA Health Care System, 3801Miranda Avenue, Palo Alto, California 94304-1290, USA. 5Department of Physiological Nursing, School of Nursing, University of California, 2 Koret Way, San Francisco, California 94143, USA.

Authors’ contributions
All of the authors contributed substantially to the conception, design, data acquisition and analysis, manuscript drafts and revisions of this study. Each has given final approval for publication.

Competing interests
Dr. Drew-Nord and Dr. Nord own the occupational medicine practice where this research was conducted and contract with various fire agencies to provide WFI services. This relationship was determined to represent no conflict of interest by the Institutional Review Board of the University of California, San Francisco. The remaining authors declare that they have no competing interests.

Received: 6 October 2010 Accepted: 25 September 2011
Published: 25 September 2011
References

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2. United States Fire Administration: Firefighter Fatality Retrospective Study, April 2002/FA-220. Edited by: Corporation T: Firefighter Fatality Retrospective Study 2006.

3. Fire Service Joint Labor Management Wellness-Fitness Initiative. [http:// www.iaff.org/HS/Well/wellness.html].

4. Froelicher VF, Myers J: Exercise and the heart. Philadelphia: Saunders Elsevier;, 5 2006.

5. Fletcher GF, Froelicher VF, Hartley LH, Haskell WL, Pollock ML: Exercise standards. A statement for health professionals from the American Heart Association. Circulation 1990, 82:2286-2322.

6. Sothmann MS, Saupe K, Jasenof D, Blaney J: Heart rate response of firefighters to actual emergencies. Implications for cardiorespiratory fitness. J Occup Med 1992, 34(8):797-800.

7. Malley KS, Goldstein AM, Aldrich TK, Kelly KJ, Weiden M, Coplan N, Karwa ML, Prezant DJ: Effects of fire fighting uniform (modern, modified modern, and traditional) design changes on exercise duration in New York City Firefighters. J Occup Environ Med 1999, 41(12):1104-1115.

8. Williams-Bell FM, Villar R, Sharratt M, Hughson RL: Physiological demands of the firefighter candidate physical ability test. Medicine and Science in Sports and Exercise 2009, 41:653-662.

9. Adams J, Roberts J, Simms K, Cheng D, Hartman J, Bartlett C: Measurement of functional capacity requirements to aid in the development of an occupation-specific rehabilitation training program to help firefighters with cardiac disease safely return to work. American Journal of Cardiology 2009, 103:762-765.

10. Mier CM, Gibson AL: Evaluation of a treadmill test for predicting the aerobic capacity of firefighters. Occup Med (Lond) 2004, 54(6):373-378.

11. Women in the fire service. [http://www.nfpa.org/itemDetail.asp? categoryID=955&itemID=23601&URL=Research/Fire%20statistics/The%20U.S. %20fire%20service&cookie%5Ftest=1], retrieved August 3, 2011.

12. Men and cardiovascular disease risk factors. [http://www.heart.org/ HEARTORG/Conditions/HeartAttack/UnderstandYourRiskofHeartAttack/ Understand-Your-Risk-of-Heart-Attack_UCM_002040_Article.jsp], retrieved August 3, 2011.

13. Healthy weight - it’ s not a diet, it’ s a lifestyle!. [http://www.cdc.gov/ healthyweight/assessing/bmi/adult_bmi/index.html#Interpreted].

14. Third report of the expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (ATP III). [http://hp2010.nhlbihin.net/ atpiii/calculator.asp?usertype=prof].

15. National Institute of Health National Heart Lung and Blood Institute: JNC7 Guidelines. 2006.

16. American College of Sports Medicine: Guidelines for exercise testing and prescription. Baltimore: Lippincott, Williams & Wilkins;, 6 2000.

17. Jensky NE, Vallejo AF, Ong MD, Schroeder ET: Validation of the Cardio Coach for sub-maximal and maximal metabolic exercise testing. Medicine and Science in Sports and Exercise 2005, 37(5):S231.

18. Dieli-Conwright CM, Jensky NE, Battaglia GM, McCauley SA, Schroeder ET:

Validation of the CardioCoach CO2 for submaximal and maximal metabolic exercise testing. The Journal of Strength and Conditioning Research 2009, 23:1316-1320.

19. International Association of Fire Fighters: The Fire Service Joint Labor Management Wellness-Fitness Initiative. Washington, D.C.: International Association of Fire Fighters;, 2 1999.
doi:10.1186/1745-6673-6-25
Cite this article as: Drew-Nord et al .: Accuracy of peak VO2 assessments in career firefighters. Journal of Occupational Medicine and Toxicology 2011 6:25.

Drew-Nord et al . Journal of Occupational Medicine and Toxicology 2011, 6:25 http://www.occup-med.com/content/6/1/25

362

THE SCIENTIFIC APPROACH TO YOUR SUCCESS

6011 N. Fresno Street, Suite 120 ● Fresno, CA 93710 ● (559) 515-3578

Program Effectiveness

Case Study – Clovis
Police Department

363

THE SCIENTIFIC APPROACH TO YOUR SUCCESS

6011 N. Fresno Street, Suite 120 ● Fresno, CA 93710 ● (559) 515-3578

Clovis Police Department

In 2008, the Clovis Police Department suspended their health screening and fitness testing program. As illustrated below, the number of claims increased until 2012 when Pinnacle Training Systems began a wellness program for these officers.

0 10
20 30
40 50
60 FY 2010 FY 2011 FY 2012 FY 2013 FY 2014 FY 2015 FY 2016 Police Department Number of Claims
Reported by Fiscal Year
$0
$100,000
$200,000
$300,000
$400,000
$500,000
FY 2010 FY 2011 FY 2012 FY 2013 FY 2014 FY 2015 FY 2016 Police Department Medical Paid by Fiscal
Year

364

THE SCIENTIFIC APPROACH TO YOUR SUCCESS

6011 N. Fresno Street, Suite 120 ● Fresno, CA 93710 ● (559) 515-3578

There has been a 50% reduction in total dollars paid from 2012-2016.

Despite the increase in the number of claims in 2016 and the medical dollars paid per fiscal year (the first increase since 2012), the total number of dollars paid and the dollars paid for temporary disability is still lower since the implementation of our program. This demonstrates the effectiveness of a well implemented program. While claims might increase in any given year, fit officers will return to work more quickly than those who are unfit reducing indemnity dollars paid. The Clovis Police Department has implemented a non-voluntary, incentivized, yet potentially punitive MOU for officers based on their overall health and fitness levels. Since the implementation of this program, the culture within the department has changed and more officers are motivated to engage in healthy behaviors. Furthermore, 4 officer’
s lives have been saved due to identifying abnormal EKG rhythms.

Based on the cost of the program and the total dollars paid since 2012 to 2016, the return on investment for this
department is 17.5:1
$0
$200,000
$400,000
$600,000
$800,000
$1,000,000
$1,200,000
$1,400,000
$1,600,000
FY 2010 FY 2011 FY 2012 FY 2013 FY 2014 FY 2015 FY 2016 Police Department Total Paid by Fiscal
Year
$0
$100,000
$200,000
$300,000
$400,000
FY 2010 FY 2011 FY 2012 FY 2013 FY 2014 FY 2015 FY 2016 Police Indemnity for Temporary
Disability Paid by Fiscal Year

365
Original Contribution
The Association of Aerobic Fitness With Injuries in the Fire Service Gerald S. Poplin *, Denise J. Roe, Wayne Peate, Robin B. Harris, and Jefferey L. Burgess * Correspondence to Dr. Gerald S. Poplin, University of Virginia, Center for Applied Biomechanics, Department of Mechanical and Aerospace Engineering School of Engineering and Applied Science, 4040 Lewis and Clark Drive, Charlottesville, V A 22911 (e-mail: [email protected]).

Initially submitted April 24, 2013; accepted for publication August 6, 2013.

The aim of the present study was to understand the risk of injury in relation to fitness in a retrospective occupa- tional cohort of firefighters in Tucson, Arizona, from 2005 to 2009. Annual medical evaluations and injury surveil- lance data were linked to compare levels of aerobic fitness in injured employees with those in noninjured employees. The individual outcomes evaluated incl uded all injuries, exercise-related injuries, and sprains and strains. Time-to-event analyses were conducted to determine the association between levels of fitness and injury likelihood. Fitness, defined by relative aerobic capacity (V O2max), was associated with injury risk. Persons in the lowest fitness level category (V O2max <43 mL/kg/minute) were 2.2 times more likely (95% confidence interval:

1.72, 2.88) to sustain injury than were those in the hi ghest fitness level category (V O2max >48 mL/kg/minute).

T h o s ew i t haVO2max between 43 and 48 mL/kg/minute were 1.38 times (95% confidence interval: 1.06, 1.78) more likely to incur injury. Hazard ratios were found to be greater for sprains and strains. Our results suggest that improving relative aerobic capacity by 1 metabolic equivalent of task (approximately 3.5 mL/kg/minute) reduces the risk of any injury by 14%. These findings illustrate the importance of fitness in reducing the risk of injury in phys- ically demanding occupations, such as the fire service, and support the need to provide dedicated resources for structured fitness programming and the promotion of injury prevention strategies to people in those fields. aerobic capacity; fire service; injury
Abbreviation: V
O2max, relative aerobic capacity.

The work demands for fire service employees are well doc- umented as requiring considerable physical abilities. In 1992, Sothmann et al. ( 1) recommended that these workers have a relative aerobic capacity (VO2max) between 38 and 42 mL/kg/ minute in order to meet the measured workload demand for firefighters while also maintaining a reserve capacity to re- spond to other unanticipated events. Since then, most fire de- partments have adopted minimum fitness standards, often
emphasizing aerobic capacity as a definitive measure of over- all fitness. Standard fitness assessments for the general pop- ulation typically have a set of norms that are scaled to age and sex, and results can range from poor to superior (2).

Opportunities for injury in the fire service are diverse. Per- sons with higher aerobic capacities should be able to consume more oxygen than those with lower aerobic capacities, and their bodies are likely to be more efficient at circulating oxygen to all systems and producing energy. Persons in the top levels of a fitness spectrum may not be as susceptible to microtraumas and may recover better from injury than their less-fit counter- parts (3–9). Hence, those with higher V
O2max should have a
lower potential for fatigue and subsequent injury. Con- versely, a high fitness level may also be an indicator that a person has an increased risk of injury, as these persons likely have greater exposure time to exercising hazards. In somefire departments, exercise has been shown to be the leading activ- ity associated with on-duty injuries (10 ).

The objectives of the present study were to establish and understand the relationship between fit n e s ss t a t u sa n dt h e risk of injury in a 5-year occupational cohort of careerfire ser- vice members. We hypothesized that firefighters deemed to be on the lower end of the fitness spectrum would be more susceptible to injury than their more fit colleagues.
149 Am J Epidemiol. 2014;179(2):149–155
American Journal of Epidemiology
© The Author 2013. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health. All rights reserved. For permissions, please e-mail: [email protected].

Vol. 179, No. 2
DOI: 10.1093/aje/kwt213
Advance Access publication:

October 31, 2013
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MATERIALS AND METHODS
Population description, data sources, and years
As previously described ( 10), the present study includes data from commissioned employees of a medium-sized met- ropolitan fire department in the southwestern United States.

Briefly, the fire department operates 21 fire stations and re- sponds to nearly 520,000 permanent residents (with seasonal increases nearing 720,000 residents). Like many other mu- nicipal fire departments, this fire department requires an an- nual physical examination to assess fitness levels and provide medical clearance for each commissioned employee. Be-
tween 2005 and 2009, data for this study were obtained from 2 sources: physical assessments from annual clinic visits and department injury surveillance reports. The present study in- cluded all commissioned (noncivilian) employees of the fire department who were employed at some point in time during the study period. Approval for and oversight of the use of hu- man subjects was provided by the University of Arizona’s In- stitutional Review Board.

Physical fitness measures
Information collected from annual exams included anthro- pometric measures (e.g., height, weight, body fat percent- age), V
O2max, muscular strength, muscular e ndurance, and
flexibility. Aerobic capacity can be de fined as the highest rate at which oxygen can be taken up and utilized by the body during rigorous exercise ( 11). Aerobic capacity is ex- pressed as a rate that is referenced in either absolute terms (L/minute) or by relative measures (mL/kg/minute) to ac- count for individual size variations. In this study, we refer to studied relative aerobic capacity. V
O2max was categorized
into 3 levels of fitness, using the 25th and 50th percentiles as the cutoff points between the “less fit” (<43 mL/kg/
minute) and “high fit” (>48 mL/kg/minute) aerobic capacity categories, respectively. The use of a percentile as the cutoff was also used in 1999 by Lee et al. (12 ), who studied the re- lationship between cardiorespiratory fitness and cardiovascu- lar disease in a large observational cohort of men. In addition, the 25th percentile closely relates to the recommended mini- mum level of aerobic capacity (42 mL/kg/minute) suggested by Sothmann et al. ( 1) that has been adopted by the National Fire Protection Association and most municipal fire depart- ments in the United States (including those in this study’ s population). The 50th percentile was chosen as the cut off for the high fit designation because of the distributional char- acteristics of the population ’s data and to remain in accord- ance with current annual physical assessment methods used by the department. Neither age nor sex was directly consid- ered when assigning aerobic fitness levels, as fire depart- ments institute a minimum standard for aerobic fitness to help ensure that all commissioned fire personnel are capable of performing the myriad of critical job tasks and responses regardless of age or sex. Maximum aerobic capacity was es- timated using the submaximal incremental treadmill protocol developed by Gerkin et al. (13 ) and guidelines suggested by the Wellness Fitness Initiative of the International Association of Fire Fighters and the International Association of Fire Chiefs (14). In brief, each participant is hooked up to a heart rate monitor and made to walk on a standard treadmill. The tread- mill’s speed and incline are increased at prespeci fied time points until the subject’ s target heart rate is reached and V
O2max can be estimated. Direct measurement of V O2max
using oxygen and carbon dioxide analyzers and monitoring of electrocardiogram output is generally limited to speci fic indications because of its higher cost.

Injury defined
Injuries that occurred on the job were recorded either if they were reportable to the Occupational Safety and Health Administration or if they were deemed nonreportable but were documented internally because of the potential for the injury to progress to the point of requiring an insurance claim (e.g., due to cumulative or repeated trauma). It should be noted that field personnel work 24-hour shifts. For the pur- poses of these analyses, reported injuries known to be only internally documented incidents with no loss of function or ability to perform duties (by review of injury report details) were excluded. In addition, cardiac events (e.g., stroke, heart attack), along with heat exhaustion, stress, and other medical issues, were excluded from injury analysis. These events were considered more likely to be indicative of an underlying set of symptoms, conditions, or diseases than to be related to an injury sustained on the job.

Statistical analyses
Data from annual physical examinations and injury sur-
veillance reports were merged utilizing unique identi fiers, which enabled a direct comparison of persons with and with- out injury. Quantitative methods, notably time-to-event re- gression models, were used to evaluate the relationship between aerobic fitness and injury. Analyses were conducted for 3 separate injury outcomes: 1) any recorded injury; 2) in- juries resulting from physical exercise; and 3) any reported sprain or strain.

For time-to-event (i.e., first injury) analyses, cumulative incidence was estimated using the life table and Kaplan- Meier methods, which allow for censoring (i.e., no injury).

Incidence rates were assessed with respect to established fit- ness measures. These levels were set using methods similar to those used for establishing aerobic fitness levels (as previ- ously explained); however, in this case, sex was taken into ac- count for measures of body fat percentage, grip strength, and flexibility. The time-to-event analysis utilized repeated mea- sures in which each time point (observation) corresponded to a person ’s annual medical examination until the occurrence of injury or censoring. This method accounted for variable observation periods because some employees were introduced later in the study period (e.g., new employees), whereas others dropped out (e.g., retired, transferred), and it enabled a single person to contribute time at risk to each of the fitness levels based on his or her most recent physical assessment. Survival analyses were completed using Cox proportional hazard regres- sion models. Statistical analyses were conducted using Stata software, version 11.2 (StataCorp LP, College Station, Texas). 150 Poplin et al.

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RESULTS
At the end of each calendar year from 2005 to 2009, there were between 577 to 694 commissioned employees within
this metropolitanfire service. During that time period, 799 em- ployees underwent at least 1 physical examination and follow- up until their first injury event or censoring. On average, the clinic database accounted for approximately 87% of the
workforce population, and the mean age was 39.2 (standard deviation, 9.6) years. Table 1 displays select summary fitness measures of the study population across the study period. The mean for V
O2max for the overall population across time was

49.6 mL/kg/minute, with a 12.2-unit difference between the minimum and maximum mean values. In total, 773 injuries were reported (Table 2). There were 357 persons who sus- tained at least 1 injury of any type, 174 who sustained at least 1 exercise-related injury, and 294 who sustained at least 1 sprain or strain injury. The median lengths of follow-up were 2.5, 3.2, and 2.8 years, respectively. A previous descrip- tive analysis of this population (for the years 2004 –2009) demonstrated that 67% of all injuries were sprains and strains, and that number increased to 89% among exercise injuries.

Thirty percent of all injuries were reported to have resulted in lost time on the job ( 10).

Kaplan-Meier analyses (data not shown) indicated that the incidence rate for injury decreased and the median time to in- jury increased with increasing age (stratified into 10-year cat- egories) (P < 0.001). There were no signi ficant differences identified between sexes; however, women acc ounted for
only 5% of the study population (as is common for the fire service (15 )). Increases in body fat percentage were related to increased incidence rate, driven most notably by those in the highest tier (>36% body fat).

Table 3 displays the general summary characteristics of the incidence of injury outcomes for V
O2max levels and repeated
measures modeling. Log-rank tests indicated that there were statistically significant increases in incidence rate with a de- cline in V
O2max for each of the 3 injury outcomes. In addition,
persons with lower V O2max levels were likely to sustain any injury sooner than were those who were more fit, as indicated by a median time to injury of 2.24 years in level III (least fit category) compared with 4.07 years for level I (most fitc a t - egory; P < 0.001).

Cox proportional hazard modeling
Results from Cox proportional hazards models are pre-
sented in Table 4. The dependent variables in these models utilized time to first injury as a function of fitness. The hazard ratios for fitness are shown with respect to 2 modeling strat- egies: 1) V O2max adjusted for age and sex and 2) V O2max ad- justed for other measures of fitness (i.e., resting heart rate, grip strength, flexibility, body fat percentage, number of con- tinuous sit-ups and push-ups, age, and sex). With a hazard ratio of 0.959 for all injuries, a 1-mL/kg/minute increase in V
O2max decreased the risk of injury 0.041 times ( P < 0.001).

The amount of work needed to complete a given task in rela- tion to the amount of energy expended during 1 minute of seated rest is referred to as the metabolic equivalent of task.

For V
O2max, a single metabolic equivalent of task is approx- imately 3.5 mL/kg/minute. Thus, these results s uggest that improving one’s aerobic capacity by 1 metabolic equivalent of task would reduce the risk for any injury by approximately 14%.

Table 5 shows the relationship between the categorical lev- els of aerobic fitness (V
O2max) for the repeated measures anal-
yses. For each injury outcome, persons with a lower fitness status (e.g., level III) had a higher hazard ratio for injury than did those in the most- fit category. For example, persons with a V O2max between 43 and 48 mL/kg/minute (level II) were 1.38 times more likely to sustain any injury than were those in the top category of VO2max (>48 mL/kg/minute). The risk of injury increased with decreasing fitness level, as those with a VO2max less than 43 mL/kg/minute (level III) were 2.2 times more likely to have any injury than were those in the top V
O2max fitness category. The hazard ratios were also found to Table 1. Mean Values of Person-Level Descriptive Statistics, Tucson, Arizona, 2005 –2009 Variable No. Mean Minimum Mean Maximum Mean Mean Difference VO2max, mL/kg/minute 782 49.6 43.6 55.8 12.2
Resting heart rate, beats per minute 797 62.9 57.2 69.2 12.0 Total grip strength, lbs a 797 229.5 211.4 247.5 36.1
Flexibility, inchesb 782 5.8 4.5 7.0 2.5
% body fat 790 18.3 15.4 20.9 5.5
Abbreviation: VO2max, relative aerobic capacity.
a 1 lb = 0.45 kg.
b 1 inch = 2.54 cm.

Table 2. Annual Frequency of Injury Outcomes, Tucson, Arizona, 2005–2009
Year No. of
Employees
No. of
Recorded
Injuries
No. of
Sprains and
Strains
No. of
Exercise-related
Injuriesa
2005 577 128 84 30
2006 625 148 100 50
2007 659 174 120 62
2008 694 199 128 81
2009 667 124 89 45
a Of all exercise-related injuries, 85.2% were sprains and strains.

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be greater when the event outcome was restricted to time to first reported sprain or strain.

Effect modification
To assess the potential of effect modi fication of the rela- tionship by age, a simple age-strati fied analysis was com- pleted for all injury outcomes, as well as for sprains and strains. Age proved to be a signi ficant modifi er of V
O2max
(P < 0.001). Table 6 presents the crude hazard ratios for the all-injury model and the sprain and strain model in relation to age (<30 and ≥30 years of age) and overall, strati fied by aerobic fitness level. For both outcome types, the risk of in- jury among those with decreased V
O2max was higher in per-
sons younger than 30 years of age than in those 30 years of age or older. Thirty years of age was chosen as our demarca- tion value primarily based on incidence rates resulting from the Kaplan-Meier analysis described above. In addition, per- sons 30 years of age or younger had a consistently increased incidence rate, regardless of the injury type. Our previous de- scriptive study of injury distributions demonstrated that fire- fighters (median age, 31 years) sustained the most injuries (30.7%), with lower injury rates for engineers, paramedics, captains, etc. (10). Given the strong relationship between age and rank and the results from Kaplan-Meier estimates, it seemed suitable to use 30 years of age as our cutoff value for assessing potential effect modification.

DISCUSSION
In the present study, we sought to better understand the as- sociation between levels of aerobic fitness and the incidence of injury using a retrospective occupational cohort. The find- ings were consistent with our original hypothesis that lower fitness levels, as defined by VO2max, would be associated with increased risk of injury. Furthermore, these increased risks were modified by age, with a larger association between fit- ness level and subsequent injury in those 30 years of age or younger. The reduction in injury risk was signi ficant for all injuries, sprains and strains, and physical exercise injuries.

These findings are especially noteworthy considering that one third of work-related injuries in this population resulted from exercise activities ( 10), further indicating the need for fitness programs with improved structure and management
relevant to the high physical demands of the job.

A number of studies have assessed the relationship be-
tween various measures of fitness and the performance of a given task, with varying results. However, in contrast to our present study, few studies have focused on assessing the as- sociation among fitness, performance, and injury risk.

Two published studies have demonstrated an increase
in injuries associated with fitness or the implementation of fitness programs (9, 16). After a baseline treadmill test to assess V
O2max, participants of the Aerobic Center Longitudi-
nal Study had their physical activity levels assessed over a Table 3. Time-to-Event Summary Statistics Between Fitness Levels and Injury Outcomes, Tucson, Arizona, 2005 –2009 Fitness
Levela
Injury Type
All Injuries Physical Exercise Sprains and Strains
IRb No. at Risk Years at Risk c IR No. at Risk Years at Risk IR No. at Risk Years at Risk I 17.5 460 921 7.3 532 1116 12.2 482 996
II 21.1 287 442 7.2 332 541 17.2 312 483
III 29.9 d 235 338 13.3 d 263 407 25.1 d 242 355
Abbreviation: IR, incidence rate.
a The relative aerobic capacity for each level was as follows: I, >48 mL/kg/minute; II, 43 –48 mL/kg/minute; and III, <43 mL/kg/minute. b Incidence rate per 100 person-years.
c Contributed time at risk (person-years).
d Statistical significance (P < 0.05) between levels using log-rank test for equality of survival functions.

Table 4. Cox Proportional Hazard Models for Assessing Aerobic Fitness and Risk of Injury, by Injury Type, Tucson, Arizona, 2005 –2009 Injury
Outcome
Model
VO2max
a VO2max Full Modelb
No. of Observations HR 95% CI No. of Observations HR 95% CI Allc 716 0.959 0.946, 0.972 710 0.953 0.939, 0.968
Exercise-related 718 0.960 0.941, 0.979 714 0.953 0.933, 0.973 Sprains and strains 718 0.952 0.937, 0.967 712 0.947 0.932, 0.963 Abbreviations: CI, confidence interval; HR, hazard ratio; V O2max, relative aerobic capacity. a Adjusted for sex and age.
b Includes independent variables: r esting heart rate, grip strength, flexibility, % body fat, number of sit-ups performed, number of push-ups performed, age, and sex.
c There were fewer subjects in this category because of lacerations that occurred during the first clinic visit, which precluded follow-up for those subjects.
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12-month period ( 16). Increased risk of musculoskeletal in- jury was associated with increases in cardiorespiratory fitness (as measured by a treadmill test), as well as increases in the amount of reported weekly physical activity. Strati fied anal- yses by physical activity type suggested that the association between cardiorespiratory fitness and musculoskeletal injury was potentially driven by unmeasured intensity levels of ex- ercise. After instituting a new fitness program among United States Air Force service members to increase fitness and participation in fitness-related activities, the mean relative V
O2max increased significantly (6.04 and 3.24 mL/kg/minute among men and women, respectively) over 3 years of the
program ( 9). The number of injuries also increased during that time, which was likely a result of increased participation in exercise activities with no embedded injury prevention program.

Two studies failed to find an association between fitness and injuries. During an 8-week basic military training regi- men, musculoskeletal injuries were assessed in relation to baseline body composition (or body mass index), aerobic fit- ness (determined by the time participants took to run 3,000 meters), health assessment measures, and age ( 17). Signi fi- cant associations were observed at a univariate level between injury and a variety of variables, including age greater than 23 years, increased body mass index, slow run times, and dys- function of back or lower limbs. Multivariate logistic regres- sions showed no relationship between injury and aerobic fitness level; however, increased body mass index, minor back and lower limb dysfunctions, and mental dysfunctions were predictive of injury. In a study of manual material han- dlers, McSweeney et al. ( 18) found no difference between exercisers and nonexercisers in terms of the likelihood of reporting an injury. However, the authors noted that in- creased or regular exercise was likely to reduce absenteeism occurrence and duration. In another study among male mate- rial handler employees at 3 separate facilities, no associa- tion was observed between injury occurrence and absolute aerobic capacity; however, a signi ficant increase in injury risk was related to a decreased V
O2max, in addition to in-
creased body fat percentage (19). It is important to note that none of the studies described above used repeated mea- sures of fitness, unlike the present study. The added strength of being able to capture time-series data for the population increased statistical power of our study and our ability to con- trol for confounding effects both within and across cohort members.

Table 5. Hazard Ratiosa for Injuries by Levels Aerobic Fitness in Repeated Measures Modeling, Tucson, Arizona, 2005–2009
VO2max
Levelb
All Injuries ( n = 716) Exercise Injuries ( n = 718) Sprains and Strains ( n = 718) HR 95% CI HR 95% CI HR 95% CI
I Referent Referent Referent
II 1.38 1.06, 1.78 1.20 0.81, 1.77 1.61 1.21, 2.13
III 2.22 1.72, 2.88 2.53 1.76, 3.64 2.63 1.98, 3.50
Abbreviations: CI, confidence interval; HR, hazard ratio, V O2max, relative aerobic capacity. a All models were adjusted for sex and age.
b The relativeaerobic capacity for each level was as follows: I, >48 mL/kg/minute; II, 43 –48 mL/kg/minute; and III, <43 mL/kg/minute.

Table 6. Age-Stratified Hazard Ratiosa for All Injuries and Sprains and Strains by Fitness Level, Tucson, Arizona, 2005–2009
Fitness Level by
Injury Typeb
Total Age <30 Years Age ≥30 Years
HR 95% CI HR 95% CI HR 95% CI
All injuries
I Referent Referent Referent
II 1.38 1.06, 1.78 2.28 1.41, 3.71 1.15 0.85, 1.57
III 2.22 1.72, 2.88 3.43 2.10, 5.58 1.86 1.36, 2.53
Sprains and
strains
I Referent Referent Referent
II 1.61 1.21, 2.13 2.27 1.32, 3.90 1.40 1.00, 1.95
III 2.63 1.98, 3.50 4.48 2.63, 7.64 2.10 1.49, 2.96
Abbreviations: CI, confidence interval; HR, hazard ratio. a All models were adjusted for sex and age within the strata. b The relative aerobic capacity for each level was as follows: I, >48 mL/kg/minute; II, 43 –48 mL/kg/minute; and III, <43 mL/kg/minute.

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Results from our study indicated that there was a modi fi- cation of injury risk based on age of the person. In particu- lar, younger employees (30 years of age or younger) with a V
O2max below that of the high fit group (i.e., VO2max <48 mL/ kg/minute) had a higher risk of injury than did their older, less fit counterparts. This effect modi fication may be due to changes in job rank (and presumably job duties and exposure to external conditions) with increasing age in firefighters.

Typically, younger personnel hold the rank of firefighter, whereas promotion or career progression tends to lead into ranks of paramedic, engineer, and captain. For most emer- gency responses, firefighters are the first to enter an emer- gency scene and are thus subject to greater hazards, known and unknown emergent threats, and time-limiting stresses.

One exception includes the risks to which paramedics are ex- posed during calls involving advanced life support. Never- theless, the hazard pro file and exposure risk for those with the rank of firefighter can be considered greater than those of their team counterparts (e.g., engineer, captain, chief ).

Limitations
Although injury events that occurred before the first ob- served clinic visit were removed to avoid left-censoring bias (a product of data merging), there was no knowledge of previous injury history. In addition, analyses were re- stricted to the first specified injury event; therefore, recurrent injuries were not assessed. Future studies on recurrent inju- ries should enhance the understanding of injuries in this pop- ulation by differentiating between the risks of repeated injuries (i.e., the same injury type suffered multiple times by a person) and those of the repeatedly injured (i.e., persons who suffer from multiple injury types). The data assessed for this study also did not permit evaluation of intrinsic factors, such as central motor control (i.e., balance), skeletal abnor- malities, alignment of joints, and ligamentous laxity ( 3–5, 20–29). Ideally, inclusion of these factors would improve fu- ture studies ( 30–32), as intrinsic risk factors each in fluence local anatomy and biomechanical limitations.

Although V
O2max is linearly related to heart rate and en-
ergy expenditure, it is an indirect measurement of an person’s maximal capacity to do work aerobically (33 ). In the present study population, VO2max was estimated using a submaximal test protocol that was previously validated and has been used widely in the fire service ( 13). Two recent studies, however, have indicated the potential for submaximal tests to overesti- mate true aerobic capacity (34, 35). If true, any overestimation of V
O2max should not in fluence the regression modeling be-
cause the potential bias would be nondifferential. Of note, the distribution of V
O2max values in our study is considered
higher than that in the general population. Standardfitness as- sessments classify midrange ( “good”) aerobic fitness at 40 years of age to be 35– 38 mL/kg/minute for women and
42–45 mL/kg/minute for men (2). The notion that firefighters are more fit than the general population is supported by the characteristics of this study ’s firefighting population, who had an average age of 39 years and a mean V O2max of 49.6 mL/kg/. These differences are likely due to the use of an em- ployed population and the active nature of the job. As previ- ously mentioned, the cutoff values established for the aerobic fitness levels in these analyses were based on the range of dis- tributions within this active population in addition to meth- ods used in other research.

When compared with the results from a previous study that described exercise-related injuries, which accounted for one third of all reported injuries, as the most common ( 10), the present findings may appear somewhat counterintuitive. It was not clear if the injuries sustained during exercise periods were the result of overexposure (i.e., fit people exercising too intensely or for too long while on duty) or if the types of ex- ercises being completed were not appropriately structured and evaluated in an effort to minimize the chances for over- exertion. The present study’s results regarding increased risks of injury among those deemed less fit suggests that the struc- ture and management of exercise within the fire service needs to be considered more intently and that employees without a physical training background should not necessarily be left to exercise without some level of appropriate programming, training, and oversight. Most professional fire departments promote or require some level of exercise among their em- p l o y e e si na ne f f o r tt oa s s u r etheir ability to complete job tasks with high physical demands (e.g., rescues). Persons in the fire service, much like the majority of the general popu- lation, can bene fit from exercise instruction and from re- sources aimed at maintaining or improving their functional fitness levels, thus reducing the potential injury loss. Given the limited financial and personnel resources, a challenge for all fire departments (and similar occupational settings) will be determining the best measures for assessing each component of functional fitness that are 1) consistent and re- liable and 2) feasible for implementation.

Conclusions
Findings from the present study provide empirical evi-
dence that lower fitness levels are associated with increased risks of injury among career fire service employees. Further- more, these increased risks were modi fied by age, which is likely due to the fact that rank, job task, and risk pro file are often associated with age in this population. As injuries con- tinue to be of relevant health concern in the fire service, the contribution of fitness to the likelihood of injury is signi fi- cant. Given that injuries are often the result of a multitude of factors and the effi ciency of every response activity in the fire service is dependent on the health and fitness of those re- sponders, comprehensive and multifaceted solutions need to be devised, applied, and distributed in order to prevent fur- ther injury loss.

ACKNOWLEDGMENTS
Author affiliations: Division of Epidemiology and Biosta- tistics, Mel and Enid Zuckerman College of Public Health, Uni- versity of Arizona, Tucson, Arizona (Gerald S. Poplin, Denise J. Roe, Robin B. Harris); Center for Applied Biomechanics, School of Engineering and Applied Sciences, University of Virginia, Charlottesville, Virginia (Gerald S. Poplin); and Division of Community, Environment and Policy, Mel and
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Enid Zuckerman College of Public Health, Tucson, Arizona (Wayne Peate, Jefferey L. Burgess).

This work was supported by grant 5R01OH009469 from
the Centers for Disease Control and Prevention, National In- stitute for Occupational Safety and Health.

We thank Emily Scobie, Becky Arnold, and all employees
of WellAmerica, who deserve our utmost gratitude for their enduring efforts throughout this project.

The contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health.

Conflict of interest: none declared.

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Firefighter Fitness: Improving Performance
and Preventing Injuries and Fatalities
Denise L. Smith, PhD
Abstract
Firefighting is dangerous work. Each year, approximately 80,000 fire- fighters are injured and about 100 firefighters lose their lives in the line of duty. Firefighters face multiple dangers in the course of their work; they encounter toxic fumes, dangerous products of combustion, high radiant heat loads, and a chaotic work environment. Despite the myriad dangers, the leading cause of line-of-duty death among firefighters is sudden cardiac event, accounting for approximately 45% of duty deaths. Firefighting requires high levels of aerobic fitness, anaerobic capacity, and muscular strength and endurance; however, data suggest that many firefighters do not possess high aerobic or anaerobic capacity.

Furthermore, many firefighters are overweight and have one or more modifiable risk factors for cardiovascular disease. The safety of the public and the health and safety of firefighters would be enhanced if firefighters followed well-designed fitness programs to improve overall health and fitness.

Introduction
Firefighters perform strenuous work in hostile, chaotic, and unpredictable conditions. Thus, firefighting is widely recog- nized as dangerous work. In 2009, there were 1.35 million fires in the United States, resulting in 3,010 civilian deaths, 17,050 civilian injuries, and an estimated total property loss of $12.5 billion (25). There are approximately 1.2 million firefighters in more than 30,000 departments providing
local communities with protection from fire and other haz- ards. Roughly 29% of the U.S. Fire Service is made up of career, paid firefighters, while the remaining 71% are vol- unteer firefighters (25).

Firefighters are a unique occupational group, and they
face multiple dangers in the course of their work; fire- fighters encounter toxic fumes, dangerous products of
combustion, high radiant heat loads,
and a chaotic work environment. In
addition to hazards encountered at the
scene of a fire, firefighters also perform
rescues, extrications, emergency medi-
cal system (EMS) calls, and respond to
natural disasters and hazardous mate-
rials spills. Attesting to the dangerous
nature of the job, approximately 80,000
firefighters are injured on the job each
year. More than 40% of the injuries
occur on the fireground, despite the
fact that firefighters spend a very small
percentage of their time engaged in fire
suppression activities. When expressed
relative to the type of call they are
responding to, approximately 23 to 25
firefighters are injured per 1,000 fires,
whereas only 0.6 to 0.7 injuries occur per 1,000 non-fire emergencies (24).

Firefighting also results in approximately 5.7 firefighter fatalities per 100,000 structure fires (13). A retrospective study, performed between 1995 and 2004, revealed that
1,006 firefighters had died in the line of duty during that period. Approximately 45% of those fatalities were the
result of cardiovascular events. While most people recog- nize that firefighting is dangerous, many believe that fire or the products of combustion account for most of the fatal- ities in the Fire Service. As seen in Figure 1, the percentage of fatalities attributed to sudden cardiac events far out- numbers the deaths due to burn or asphyxiation on a con- sistent basis.

Physical Demands of Firefighting
Firefighting involves a unique set of stressors (Fig. 2).

Firefighters perform strenuous muscular work; they must climb stairs and ladders, carry and use heavy tools, often above their head or in awkward positions, and they may be called upon to perform difficult rescue operations. Fire- fighters work in dangerous environments; they encounter extreme temperatures, toxic smoke (including carbon mon- oxide and hydrogen cyanide), and chaotic conditions that include loud noise and low visibility. Further, this work must be done with time urgency and is often performed
under the psychological stress of knowing that civilians are

TRAINING
www.acsm-csmr.org Current Sports Medicine Reports 167
Professor of Health and Exercise Sciences, Skidmore College, Health and Exercise Sciences, Saratoga Springs, NY; Research Scientist, University of Illinois, Fire Service Institute, Champaign, IL Address for correspondence: Denise L. Smith, PhD, Professor of Health and Exercise Sciences, Skidmore College, 815 N. Broadway, Saratoga Springs, NY 12866 (E-mail: [email protected]).
1537-890x/1003/167Y172
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373
in imminent danger. Additionally, firefighters must perform their work while wearing personal protective equipment
(PPE), equipment that is necessary to protect the firefighter but that also imposes a considerable physiological burden because of its weight, insulative properties, and restrictive- ness. The unique set of stressors that are encountered dur- ing firefighting results in substantial physiological strain, particularly to the thermoregulatory and cardiovascular systems.

Physiological Strain of Firefighting
Considering the work that is done and the environment
in which it is performed, firefighting is among the most arduous work that humans undertake. Not surprisingly
then, firefighting affects every system of the body. Figure 3 summarizes some of the major effects of firefighting on the body.

While firefighting results in significant physiological strain affecting nearly every system of the body, statistically the greatest risks to the firefighter come from the cardiovascular and thermal strain associated with firefighting. Strenuous firefighting activities lead to near maximal heart rates (HR) that can remain elevated for extended periods of time (1,38).

Stroke volume decreases following strenuous firefighting activity (38). Firefighting may result in high blood pressures that quickly drop below resting values following cessation of work (21).

Firefighting is associated with profuse sweating and hence a decrease in plasma volume. A 15% reduction in plasma
volume has been reported after 18 min of strenuous fire- fighting drills (38). The decrease in plasma volume contrib- utes to the reduction in stroke volume noted above and leads to hemoconcentration. Hemoconcentration causes a change in blood electrolytes and increases blood viscosity (39).

Platelet number increases (more than can be explained by hemoconcentration) and platelet aggregability increases fol- lowing firefighting activity (41).

Given that firefighters wear heavy, insulative PPE that often weighs in excess of 22 kg and are called upon to per- form strenuous muscular work in very hot environments,
it is no surprise that firefighting leads to thermal strain.

Challenges to the thermoregulatory system include elevated core temperature (hyperthermia) and dehydration. Hyper- thermia and dehydration are very serious problems in the Fire Service because these twin challenges can hasten the onset of fatigue and limit work time, add to cardiovascular strain, lead to fatal heat illnesses (including heat stroke), impair cognitive function, and increase the risk of injury.

Core temperature increases rapidly but does not reach
drastically high levels during short-term firefighting. Peri- ods of 18 to 20 min of firefighting have been reported to cause an average increase in body temperature of 1.5 to

2.5-F (21,40). Prolonged firefighting or repeated evolutions of training would cause greater elevations in body temper- ature. Firefighting, like other strenuous activity, leads to fatigue. The fatigue may be due to neural, metabolic, or muscular factors and is likely hastened by work in the heat.

Fatigue can impair the firefighting mission and may increase susceptibility to injury.

Performance Requirements
Firefighting requires high levels of aerobic fitness, anaer- obic capacity, and muscular strength and endurance. Addi- tionally, given the detrimental effects of excess body fat, firefighters also should possess an appropriate body compo- sition. Several studies have attempted to quantify the aerobic Figure 1: Firefighter casualty statistics from 1990 to 2008.

Based on data from The National Fire Protection Association (NFPA).

Figure 2: Unique job stressors. Stressors associated with firefighting include strenuous muscular work, heavy personal protective equipment (PPE), and a hot and dangerous environment.
168 Volume 10 & Number 3 & May 2011 Firefighter Fitness Copyright © 2011 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.

374
requirements of firefighting. A limitation to all of these stud- ies is that they ‘‘simulate’’ firefighting activity. Further, the work that must be performed varies greatly based on the work assignment (e.g., officer, venting, advancing a charged hose line, performing a rescue). Studies have reported
the estimated oxygen consumption associated with fire-
fighting to range between 33.6 and 49.0 mL Ikg
j1Iminj1
(17,26,28,44). Sothmann and colleagues (1990) devised
a simulated set of firefighting drills that took approxi- mately 9 min to complete (44). The participants had
an average V˙ O2max of 39.9 mLIkgj1Iminj1 a n dw o r k e da t approximately 76% of their V ˙ O2max to complete the
simulated drills (44). To validate a minimum V ˙ O2max
requirement, the researchers recruited another group of firefighters (V˙ O
2max range 26Y51 mLIkgj1Iminj1) and had
them perform the fire-suppression drills. Seven of 10 fire- fighters with a V ˙ O
2max of 33.5 to 41.0 mL Ikgj1Iminj1
were able to successfully complete the drills within the allotted time. All participants with a V˙ O
2max greater than
41 mLIkgj1Iminj1 were able to complete the fire-suppression activities within the acceptable timeframe. Based on re- search findings, the National Fire Protection Association (NFPA) Standard on Occupational Medical Programs for
Fire Departments recommends that firefighters have a mini- mal aerobic capacity of 42 mLIkg
j1Iminj1 (metabolic equiv-
alent of task score, 12) (31).

Firefighters also must have a high anaerobic capacity to perform certain job tasks. Strenuous firefighting relies on anaerobic energy sources (in addition to aerobic sources) and high lactate values (6Y13 mmol) have been reported fol- lowing demanding firefighting simulations (2,17,26).

Muscular strength and endurance also are important to
meet the physical demands placed on firefighters. Muscular strength and endurance are necessary for forcible entry, advancing the fire hose, chopping tasks, and victim rescues.

Sothmann and colleagues (2004) have sought to validate
minimally acceptable standards for muscular strength and endurance necessary to successfully perform firefighting tasks (43). Participants completed a simulated set of fire- fighting tasks and a battery of tests of physical abilities. The researchers found that physical ability tests (hose drag/high rise pack carry, arm lift, and muscle endurance) combined to significantly predict performance time on the simulated firefighting tasks. Rhea and colleagues (2004) investigated the relationship between several fitness scores and job per- formance (assessed by performance time on a simulated hose pull, dummy drag, stair climb, and hose hoist) (34). These authors reported high correlations between measures of
muscular strength, muscle endurance, anaerobic perform- ance, and performance times.

Fitness Profile of U.S. Firefighters
Given the heterogeneous nature of the U.S. Fire Service, it is difficult to get an accurate, generalizable assessment of the ‘‘typical’’ firefighter. Firefighter fitness profiles are likely to vary greatly depending upon region of the country, career or volunteer status, the age of the firefighter, and the hiring, medical, and fitness policies of the department.

Aerobic Capacity
Despite the physically demanding aspects of the job, sev- eral studies have reported that firefighters do not possess above-average aerobic capacity. Again, caution must be used when interpreting the literature because many articles report fitness values on a small number of firefighters, from a single department or small group of departments. Furthermore,
many of the aerobic fitness values reported in the literature are based on submaximal exercise tests. In general, reported aerobic fitness values for firefighters range from 35 to 56 mL Ikg
j1Iminj1 (9,35,37,49). An early study that ran-
domly sampled 150 firefighters from a large metropol-
itan city found that aerobic capacity significantly decreased from the 20- to 25-yr-old group (47.7 mL Ikg
j1Iminj1)t o
the 30- to 35-yr-old group (37.9 mLIkgj1Iminj1) and from the 35-yr-old group to the 40- to 45-yr-old group
(31.5 mL Ikg
j1Iminj1). In each case, however, the fire-
fighters’ aerobic capacity was similar to that predicted for sedentary individuals (37). In contrast, Davis and colleagues (2002) studied a small municipal fire department on the West Coast and found that firefighters in the 20- to 29-yr age Figure 3: Primary physiological responses to firefighting and the benefits of physical fitness. Firefighting results in considerable physio- logical strain. A well-designed fitness program provides multiple benefits and helps prepare the firefighter for the demands of firefighting. www.acsm-csmr.org Current Sports Medicine Reports 169
Copyright © 2011 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.

375
group had an aerobic capacity of 55.9 mL Ikgj1Iminj1 and that the oldest group, 50 Y59 yr, had an oxygen uptake of

40.4 mL Ikgj1Iminj1 (9). In every decade-group, the fire- fighters’ aerobic capacity was higher than age-predicted values (9). While it is tempting to hope that the improve- ments in aerobic capacity cited in the more recent study reflect positive changes relative to fitness patterns among the Fire Service, other evidence suggests that firefighters possess modest aerobic capacity (7,9,49). A study of over 100 recruit firefighters in a metropolitan fire department found that recruit firefighters entered the fire service with an aerobic capacity of 35 mLIkg
j1Iminj1 (9). Encouragingly,
the study went on to document a 28% increase in aerobic capacity following a 16-wk fitness program.

Muscular Strength and Endurance
In general, firefighters have high levels of muscular
strength and endurance (2,9,29,34,35,43). Muscular strength and endurance are necessary to perform common firefight- ing activities, such as carrying ladders, advancing charged hose lines, and using heavy equipment. Firefighters rely on upper- and lower-body strength to perform their jobs. Fur- ther, core muscular strength also may serve to reduce the incidence of injuries (48). The high level of strength reported in the fire service also may reflect cultural values within the Fire Service.

Obesity
There is considerable evidence of a high prevalence of
obesity among U.S. firefighters (7,12,16,42,46,50). Clark and colleagues (2002) investigated the body mass index
(BMI) and health status of a group of municipal firefighters and reported that 80% of the firefighters were overweight or obese and that there was a significant increase in systolic blood pressure, diastolic blood pressure, cholesterol, and triglycerides as firefighters increased in fatness category (7).

Conversely, V˙ O
2max and METS decreased with increasing
fatness (7). A study involving a large group of career fire- fighters ( N = 332) found that at baseline testing, 53% of firefighters were overweight (BMI between 25 and 29.9), with an additional 35% classified as obese (BMI Q 30).

Additionally, obese firefighters were more likely to have hypertension and low levels of high-density lipoprotein- cholesterol (42). A study of more than 100 career and
volunteer firefighters with no known history of cardio- vascular disease, stationed throughout Illinois, found an average BMI of 28.1 and that 75% of the participants had a BMI greater than 25 (12). Furthermore, Fahs and col-
leagues (2009) reported that increased BMI was associated with increased arterial stiffness (12). In addition to the high prevalence of overweight and obesity in the Fire Service, there is evidence that firefighters are getting heavier over time. Soteriades et al. (2005) found that over a 5-yr follow- up period, the prevalence of obesity increased from 35% to 40%, and the proportion of firefighters with extreme obe- sity increased fourfold (from 0.6% to 2.4%) (42).

Cardiovascular Risk
Most studies that have compared the overall car-
diovascular mortality of firefighters with the general public have found that firefighters do not have an increased risk for cardiovascular death, except in instances where the careers of firefighters included significant time on the job before the use of respiratory protection (11). Studies in Boston, Connecticut, New Jersey, San Francisco, Seattle, Edmonton/Calgary and Florida all have found no associa- tion between cardiovascular mortality and occupation
(3,10,14,18,27,30,36,47). Similarly, a recent review found that firefighters have similar risk profiles for obesity, hypertension, and hyperlipidemia compared with the gen- eral population (11).

Mismatch Between Fitness Demands
and Fitness Profiles
Given that so much of a firefighter’s time is sedentary, perhaps it is not surprising that they do not differ from the general population in fitness, obesity, or other cardio- vascular risk factors. However, considering that their work is punctuated by periods of intense activity, these risk pro- files may explain why sudden cardiac events are the leading cause of line-of-duty deaths among firefighters; essentially, there is a mismatch between the fitness and health require- ments of strenuous firefighting and the current fitness pro- file of the U.S. Fire Service.

Fitness Recommendations
Current standards recommend that firefighters partic-
ipate in a fitness program (22,32), but it is the responsibility of each individual department to determine whether to
institute a fitness program. The NFPA 1583 Standard rec- ommends a program that is positive, nonpunitive, and does not set fitness standards. Of the 440 firefighter fatalities investigated by the National Institute of Occupational
Safety and Health (NIOSH) during the period from 1995 to 2004 (44% of fatalities during that period; 440 of 1,006), 39% of the departments offered a voluntary fitness pro- gram, but only 8% had mandatory participation (33).

Cardiovascular events are by far the leading cause of line- of-duty deaths among firefighters. Additionally, cardiac events are disproportionately related to fire suppression activities, with firefighters having a 10- to 100-fold in- creased risk of experiencing a fatal cardiac event after fire suppression versus normal duties at the station (23). Thus firefighters should have a high level of cardiovascular fit- ness in order to improve performance and decrease the risk of on-the-job fatalities associated with strenuous activity.

Additionally, nearly 80,000 firefighters are injured each year, with a large percentage of these injuries occurring during fireground operations. Clearly, fitness has an im- portant role to play in preparing firefighters for the stren- uous activity they encounter during firefighting activity.

Appropriate fitness programs can enhance overall health, improve performance, and lessen the risk of firefighter injury or fatality. Firefighters and the public they serve will benefit from more fitness programming in the Fire Service.

Fitness Prescription for Firefighter Health and Safety
Firefighting is strenuous physical work and places con- siderable strain on the body. In order to meet the unique physical demands of firefighting and to perform firefighting in a safe manner, firefighters must be physically fit. Like soldiers and elite athletes, firefighters should be physically 170 Volume 10 & Number 3 & May 2011 Firefighter Fitness Copyright © 2011 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.

376
prepared to meet the unique physical challenges they face.

Figure 3 depicts the direct ways in which a fitness program can mitigate against the physiological strain of firefighting.

Fitness prescriptions for firefighters must meet certain criteria in order to adequately serve the U.S. Fire Service.

Prescriptions need to address the unique and specific phys- iological demands of firefighting. This is difficult to accom- plish because of the current diversity in fitness and health status of firefighters. Fitness prescriptions must recognize the unique structure and culture of volunteer and career fire departments. These prescriptions also must include indi- vidual and progressive programs to meet the individual
needs of low-fit to highly-trained firefighters.

Aerobic Training
Aerobic training provides several health benefits, includ- ing improved body composition, serum lipids, glucose
metabolism, and maximal aerobic capacity (20). While
moderate-intensity aerobic exercise (50% Y70% HR
max)i s
widely recommended for health benefits, research suggests that higher-intensity aerobic exercise training may promote weight loss and cardiovascular improvements to a greater extent (8). Given the physical demands of firefighting, and the high proportion of line-of-duty deaths attributed to cardiac events, it is essential that a training program for firefighters include endurance training.

Sprint Interval Training (SIT)
SIT is a type of high-intensity interval training (HIT) that is designed to improve endurance, increase anaerobic
threshold, and improve maximal performance. This type of training has been shown to be effective at increasing aerobic capacity (6), improving endurance capacity when working at 80% of aerobic capacity (4), enhancing aerobic metabo- lism (19), and increasing muscle glycogen content and the maximal activity of citrate synthase (5). Given the effec- tiveness and efficiency of these workouts and the degree to which they mimic actual energy expenditure during an
emergency, it is reasonable to include SIT in exercise pre- scriptions for firefighters. However, given the high intensity of the workouts and the heterogeneity of fitness levels in the Fire Service, it may be prudent to initiate exercise programs at a lower intensity and increase progressively.

Functional Training
Functional training targets movements that are necessary for activities of daily living (45). Functional training utilizes full-body, dynamic movements to increase muscular strength and endurance as well as aerobic capacity using equipment such as medicine balls, physioballs, and exercise bands to provide resistance. This type of exercise mimics the high- intensity demands of firefighting. In fact, functional training workouts have been gaining popularity among progressive Fire Departments. CrossFit workouts are now embraced by many members of the Fire Service.

Resistance Training
Resistance training increases muscle mass and function.

Muscle strength and endurance routinely have been found to predict performance on simulated firefighting activities and are unquestionably important for firefighters. Addition- ally, resistance training is associated with a decreased risk of all-cause mortality, the development and maintenance of lean muscle mass, and enhanced glucose metabolism
(15,20). Resistance training should be part of every fire- fighter’s fitness program. Not only will it improve work capacity, it is likely to provide protection against injuries, especially muscular strains, on the fireground.

Lifestyle Modifications
There must be a cultural change within the U.S. Fire
Service in order to improve fitness and decrease injuries and cardiac events. Changes should include a fitness program designed to improve aerobic capacity, muscle strength and endurance, and functional capacity. The fitness program and a sound dietary plan also should seek to promote
healthy weight for firefighters. The development of a social support system with adequate leadership and incentives
should promote healthy lifestyle changes. Each individual firefighter and Fire Department must set short- and long- term goals that are realistic and measureable as well as easy to implement within the constraints of space, equipment, and other duties.

Conclusion
Firefighting is strenuous and dangerous work with a
unique set of stressors. In order to meet the physical
demands of firefighting, firefighters must be physically fit.

Firefighters who possess high levels of cardiovascular and muscular fitness are better able to serve the public by per- forming their job more effectively. Fit firefighters have increased mobility, energy, and endurance, allowing them to better perform job duties efficiently and safely, and fit fire- fighters also are less likely to jeopardize the safety of their fellow firefighters or the public they serve.

The safety of the public and the health and safety of
firefighters would be greatly enhanced if firefighters fol- lowed well-designed fitness programs to improve overall health and fitness. Exercise scientists can play an important role in enhancing firefighter’s fitness, thereby improving public health and safety. Specific fitness programs that meet the needs of a broad range of individuals within the Fire Service must be developed that are tailored to the specific job requirements that firefighters face. These fitness pro- grams should be geared toward improving health, safety, and performance. In order to be adopted, these programs must be sensitive to the diverse needs in the Fire Service.

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Cardiovascular Strain of Firefighting and the Risk of
Sudden Cardiac Events
Denise L. Smith1,2, Jacob P. DeBlois1,S t e f a n o sN .K a l e s3,4, and Gavin P. Horn 2 1Health and Exercise Sciences, Skidmore College, Saratoga Springs, NY; 2University of Illinois Fire Service Institute, Champaign, IL; 3Department of Environmental Health, Harvard TH Chan School of Public Health, Boston, MA; 4Occupational Medicine, Cambridge Health Alliance/Harvard Medical School, Cambridge, MA SMITH, D.L., J.P. DEBLOIS, S.N. KALES, and G.P. HORN. Cardiovascular strain of firefighting and the risk of sudden cardiac events. Exerc. Sport Sci. Rev., Vol. 44, No. 3, pp. 90 –97, 2016. Approximately 45% to 50% of line-of-duty deaths in the fire service are caused by sudden cardiac deaths, which most often occur during or shortly after firefighting duties. We present a theoretical model linking the cardiac, vascular, and hematological responses of firefighting to the triggering of sudden cardiac death in susceptible individuals.

Key Words: firefighting, cardiac, vascular, coagulatory, cardiovascular disease, sudden cardiac death.

Key Points
 The leading cause of duty-related death within the fire service is a sudden cardiac event, accounting for ap-
proximately 50% of line-of-duty deaths.
 Sudden cardiac events are much more likely to occur af- ter firefighting activities than other duties and may be the result of primary arrhythmias or myocardial infarction.  Firefighting leads to significant cardiovascular strain, in- cluding alterations in cardiac function, vascular func- tion, and hemostasis.
 Most firefighters recover from the stress of firefighting without incident. However, the cardiovascular strain of firefighting may trigger a cardiovascular event in fire- fighters with an underlying disease.
 Increased cardiac work, vascular dysfunction, tissue is- chemia, and a procoagulatory state may be important
causal links that increase the risk of sudden cardiac
events in the vulnerable firefighter.

INTRODUCTION
Firefighters respond to multiple types of emergencies, such as fires, vehicle/machinery accidents, medical calls, calls for public assistance, technical rescue, and hazardous materials spills to protect the communities they serve. However, statistics show that firefighting (i.e., those activities directly related to fire suppression) results in the greatest risk of injury or fatality (8).

Firefighting activities often are conducted in immediately dan- gerous to life or health conditions that may expose firefighters to extreme environmental temperatures and to multiple chem- ical and particulate hazards. These conditions necessitate that firefighters wear heavy, insulated, and restrictive personal pro- tective equipment (PPE). Hence, it comes as no surprise that firefighting results in high levels of cardiovascular strain.

Fire service statistics reveal that despite all the acute trau- matic risks that firefighters face ( e.g., burn injuries, smoke inhalation, structural collapse), by far, the leading cause of line-of-duty death is cardiac related. In fact, approximately 45% to 50% of all firefighter duty –related fatalities are caused by sudden cardiac death (SCD) — ap r o p o r t i o nt h a ti sr e l a - tively stable and stubbornly high. This point is highlighted in Figure 1, which compares SCD with fatalities from burns and asphyxiation since 1990. The number of cardiac fatalities seems to be trending downward during the past 10 years. This encour- aging trend may be caused by efforts by the International Asso- ciation of Firefighters, the International Association of Fire Chiefs, and the National Volunteer Fire Council, all of which have undertaken rigorous campaigns to increase medical evalu- ations and to promote firefighter wellness and fitness. However, as the numbers indicate, considerable work remains to further reduce cardiac fatalities in the US Fire Service (Fig. 1).

Importantly, sudden cardiac events are disproportionately more likely to occur during or after a firefighting activity than other duties. Although firefighters spend a small percentage of their time (1%–5%) engaged in fire suppression activities, more Address for correspondence:Denise L. Smith, Ph.D., Health and Exercise Sciences, Skidmore College, 815 North Broadway, Saratoga Springs, NY 12866 (E-mail: [email protected]).

Accepted for publication: February 29, 2016.

Associate Editor: Bo Fernhall, Ph.D., FACSM
0091-6331/4403/90–97
Exercise and Sport Sciences Reviews
DOI: 10.1249/JES.0000000000000081
Copyright © 2016 by the American College of Sports Medicine Editor's note: Go online to view the Journal Club questions in the Supplemental Digital Content: see http://links.lww.com/ESSR/A19. 90 ARTICLE
Copyright © 2016 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.

379
than 30% of cardiac fatalities occur during or shortly after firefighting activity, resulting in a 10 to 100 times greater risk of sudden cardiac events after firefighting versus station du- ties (19). Furthermore, there are approximately 17 to 25 duty- related nonfatal cardiovascular events (heart attacks and strokes) for every fatal event (8,15).

Cardiac events are devastating for individual firefighters and their families, but because firefighting relies on a coordinated team effort, duty-related cardiac events also can jeopardize job performance and the safety of other firefighters and may com- promise the ability of firefighters to protect civilians during emergencies. Cardiac injuries likewise often will require signifi- cant time away from the fire department at significant cost and burden to the local fire department. Hence, there is an impor- tant public safety concern about cardiovascular events in the fire service. We recently have published a review that proposed a theoretical model highlighting the interaction of occupa- tional, medical, and behavioral risk factors in contributing to underlying cardiovascular disease (CVD) (coronary heart dis- ease (CHD) and/or structural heart disease) and where the strenuous duties of firefighting may trigger a cardiovascular event (Fig. 2) (32). In the current review, we extend the prev- ious model by detailing results of translational research documenting the cardiovascular strain of firefighting and fur- ther highlighting the potential mechanisms by which cardio- vascular responses to firefighting may lead to pathophysiologic changes that can trigger fatal arrhythmias or myocardial infarc- tion, thus leading to a sudden cardiac event (Fig. 3).

FACTORS AFFECTING THE CARDIOVASCULAR

STRAIN OF FIREFIGHTING
Firefighting involves performing a complex series of physi- cally demanding tasks under psychologically stressful conditions within arduous environments. As depicted in Figure 3, the car- diovascular strain of firefighting results from multiple interact- ing factors including 1) sympathetic nervous system activation; 2) the strenuous physical work (aerobic and anaerobic); and 3) exposure to environmental conditions and pollutants contained in fire smoke.

Sympathetic Nervous System Activation
Sympathetic nervous activation begins with the alarm and continues throughout a fire call. The sudden sounding of an alarm increases psychological/mental stress, activating the sym- pathetic nervous system. While on the call, sympathetic activa- tion continues because the fire scene is a dynamic cluttered environment in which fire behavior can change rapidly and where loud noises, time urgency, and potential danger produce powerful sympathetic arousal. Several studies have shown a fivefold to sevenfold risk of sudden cardiac events during alarm response versus nonemergencies (19,20). The increased relative risk of a cardiac event during this period can be attributed largely to sympathetic arousal and a putative surge in catechol- amines because there is not yet exposure to the fire environ- ment or the requirements for large amounts of physical work.

Physical Work
Structural firefighting requires a combination of static work and aerobic exertion, such as stair and ladder climbing (while Figure 1. Line-of-duty deaths by major cause since 1990.

Figure 2. Theoretical model of occupational, medical and behavioral risk factors that contribute to sudden cardiac events following firefighting activities. Note that there is overlap between occupational and lifestyle risk factors. Arrows indicate that factors can be associated with progression or regressiono fr i s kf a c t o r s and subclinical disease. EtOH, alcohol; CHD, coronary heart disease; LVH, left ventricular hypertrophy; CVD, cardiovascular disease. (Reprinted from (32). Copy- right © 2011 Wolters Kluwer Health. Used with permission.) Volume 44  Number 3  July 2016 Firefighting and Sudden Cardiac Events 91 Copyright © 2016 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.

380
carrying heavy equipment), forcible entry, victim search and rescue, building ventilation, and fire attack and suppression. Al- though it is known that different firefighting tasks require dif- ferent levels of energy expenditure, firefighting often results in oxygen consumption of greater than of 40 mL ∙kg
−1∙min−1
(24). The strenuous work of firefighting is performed while wearing heavy (≥25 kg) and fully encapsulating PPE that pro- vides range-of-motion restrictions, heavy insulation, and lim- ited breathability and adds to the metabolic demands of firefighting. In addition, fire fighters perform a great deal of upper body work (lifting and carrying heavy equipment, hose movement and control, chopping, ceiling overhaul), and upper body work (such as wood chopping or snow shoveling) leads to an exaggerated blood pressure response and an increased car- diac work and is associated with an increased risk of a sudden cardiac event (12).

Environmental Conditions
Radiant heat from a fire adds considerably to the heat stress experienced by firefighters. We have reported an increase in core temperature ( T
co) of approximately 1.5°C after short-
term (≤20 min) firefighting activity (30), and the rate of Tco change increased with subsequent firefighting activities (17).

Both heat stress and dehydration exacerbate cardiovascular strain associated with heavy work (9).

Although firefighters regularly use self-contained breathing apparatus to protect their airways while operating inside the structure, firefighters routinely are exposed to fire smoke (out- side of the structure and during overhaul/cleanup operations), which contains toxic and asphyxiant gases such as carbon mon- oxide, hydrogen cyanide, hydrogen sulfide, and particulate mat- ter among a myriad of other chemicals (5). When inhaled, carbon monoxide reduces the availability of oxygen, thus, po- tentially resulting in tissue hypoxia. Tissue hypoxemia caused by carbon monoxide and other asphyxiants (e.g., hydrogen cy- anide, hydrogen sulfide) may lead to myocardial ischemia in susceptible individuals. Fire smoke also contains particulate matter associated with the promotion of arrhythmias, decreased heart rate variability, and increased blood pressure (23). Such particulates also may increase the formation of free radicals leading to activation of proinflammatory and prothrombotic pathways that may cause endothelial dysfunction and increased blood coagulability.

CARDIOVASCULAR RESPONSES TO FIREFIGHTING
Firefighting operations are complex, and no fire scene is iden- tical to another. The magnitude of the cardiovascular strain is af- fected by the fuel that is burning (e.g., heat release rate, products of combustion), the size of the fire (amount of fuel involvement), dimensions and layout of the structure, the resources (human and equipment) that are available to fight the fire, the tactics that are used (e.g., interior, exterior, or combination attack), and the fire- fighter's assigned task. For example, a firefighter who is responsi- b l ef o ro p e r a t i n gt h ep u m po nt h ee n g i n ea tas m a l lf i r ew o u l d have a different level of cardiac strain than a firefighter who is performing search and rescue activities on the interior of a large structure during fire suppression activities. The following sections detail research efforts to characterize systematically the effects of firefighting on the various components of the cardiovascular system — the heart, vasculature, and hemostatic system.

Cardiac Responses
During strenuous fire suppression activities, heart rates (HR) increase and rise to maximal or near maximal levels andT co in-
creases rapidly (18,29). Studies that have focused on long- term firefighting activities that require more than 1 cylinder of air (supporting heavy firefighting work for approximately 12–16 min) have shown that the rate of increase in T
co is
Figure 3. Theoretical interplay between cardiac, vascular, and hemostatic responses to firefighting and sudden cardiac events in susceptible individuals.

RH, reactive hyperemia; BF, blood flow; Fxn, function; SEVR, sub-endocardial viability ratio; SV, stroke volume; RPP, rate pressure product; SS, shear stress. 92 Exercise and Sport Sciences Reviews www.acsm-essr.org Copyright © 2016 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.

381
augmented in later bouts of activity, further exacerbating car- diovascular strain and leading to higher HR (17). HR responses to firefighting vary tremendously depending on the type of work the firefighter is doing and mu ltiple other factors (ambient temperature, length of time engaged, fitness level, etc.). Fur- thermore, firefighters' HR vary throughout a given emer- gency because of the intermittent nature of the work (17).

Although HR is the most frequently documented cardiovas- cular variable because of its ease of measurement, alterations in other cardiac variables are likely even more important to de- scribe the cardiovascular risk associated with firefighting. We have reported a 35% reduction in stroke volume (seated posi- tion) after three short bouts of strenuous firefighting activity that lasted a total of approximately 20 min (29). More recently, we performed a full echocardiographic examination (supine po- sition) before and after a 3-h training period that included mul- tiple training evolutions/drills, each lasting approximately 15 to 30 min (11). The firefighting training resulted in near maximal HR (mean, 192 ± 15 beats min
−1) and an increase in Tco from

37.1 ± 0.5°C to 38.9 ± 0.6°C. Echocardiographic measure- ments were obtained within 30 min of firefighting, and mean HR had decreased to 90 ± 13 beats min −1 at the time of mea- surement. In this study, we found a 13% reduction in stroke vol- ume (11). Furthermore, the repeated bouts of training resulted in significant reductions in left ventricular diastolic size and vol- ume, transmitral flow velocities, mitral E/A (the ratio of passive ventricular filling to active atrial filling of the ventricle), and left ventricular shortening fraction and ejection fraction. The changes in left ventricular function observed in this study may reflect changes in preload after the firefighting activity. However, there is some evidence that intrinsic systolic and diastolic func- tion also may be depressed after firefighting activity. TDI-E ′, an indicator of rate of ventricular relaxation, decreased by 19% when measured at the lateral wall but was unchanged when measured at the septal wall (11). The decline in the lat- eral wall TDI-E ′ is a marker of lusitropic function that is less load dependent than other measures of diastolic function. Al- though the clinical significance of the cardiac changes pre- sented above are not fully comprehended, it is important to consider these changes in the context of overall cardiovascular function, especially given that these results were noted in ap- parently healthy firefighters with no known CVD. Indeed, this study found that, in addition to decreased left ventricular func- tion, there was a decrease in systemic arterial compliance (11).

These findings raise the possibility that arterial-ventricular cou- pling may be altered with firefighting and reinforces the impor- tance of investigating vascular function after firefighting.

Vascular Responses
The myocardium and vasculature work together in a con-
certed effort to deliver blood to body tissues. Changes in vascu- lar function and/or the interaction between the myocardium and the vasculature may lead to tissue ischemia/hypoxia, pre- cipitating a sudden cardiac event. We have conducted several studies to investigate the effects of firefighting activities and heat stress on the vasculature and its function.

Yan et al. (35) reported changes in arterial-ventricular cou- pling after repeated bouts of firefighting during a 3-h period of live-fire training in a group of young (28 ± 1 yr) firefighters.

Arterial-ventricular coupling was measured on the right common carotid artery using wave intensity analysis, a hemody- namic index in which changes in blood pressure and blood flow provide insights into cardiovascular stress (25). In response to live-fire training, wave 1 amplitude, an indicator of cardiac con- tractility, was reduced by approximately 28%, suggesting that systolic function decreased (35). In a laboratory study designed to further investigate the role of heat stress in changing arterial- ventricular coupling, Smith et al. (26) examined 11 young (22 ± 3 yr) men before and after a 100-min exercise/rest tread- mill task (alternating 20-min walk/20-min rest in structural firefighting PPE) and found a nearly 32% increase in wave 2 amplitude. This measure of end-systolic/early-diastolic ventric- ular function from wave intensity analysis indicates increased afterload on the myocardium after heat stress (26).

We also have examined the influence of firefighting on vas- cular structure and function. Fahs et al. (6) examined the acute effects of live-fire training drills on arterial stiffness and limb blood flow in a group of 69 male firefighters (mean age, 28 ± 1 yr). After 3 h of live-fire training, hemodynamic proxies (wave reflection time and augmentation index) influenced by aortic stiffness increased by approximately 3%. Despite a possi- ble increase in aortic stiffness, a concomitant increase in pe- ripheral forearm vascular conductance (80%) and hyperemia (32%) also were observed (6). It is suggested that the unique combination of thermal, metabolic, psychological, and mental stress that occurs with firefighting activities might explain the increased aortic stiffness and forearm blood flow.

As a follow-up to live-fire studies, Lefferts et al. (22) con- ducted a laboratory-based study to isolate the influence of ther- mal stress on vascular and central hemodynamic changes.

Controlling for hydration status, Lefferts et al. (22) reported that exercise-induced moderate heat stress (T
co of 37.8 ± 0.1°C
caused by treadmill walking in firefighting PPE) did not change aortic stiffness (pulse wave velocity, pre: 5.0 ± 0.1 m·s −1 vs post:

4.9 ± 0.1 m·s −1; P =0 . 6 9 8 ) .H o w e v e r ,L e f f e r t set al. (22) did find alterations in myocardial work demands (rate-pressure pro- duct increased by 37%) and an indirect proxy of coronary per- fusion (subendocardial viability ratio (SEVR) reduced by about 27%). After a short 18-min bout of live-fire activity, Hornet al. (18) found a larger increase in rate-pressure product (80% – 95%) and similar reductions in SEVR (30% –35%). These re- sults, although they must be interpreted cautiously given lim- itations with SEVR, suggest a potential mismatch between myocardial oxygen demand and supply, which may result in is- chemia during strenuous work in the heat. This potential mis- match may be more pronounced after firefighting activities than exercise-induced heat stress.

Thus, firefighting activity and heat stress may result in vascular dysfunction and arterial-ventricular uncoupling as evidenced by increased central arterial stiffness, decreased vascular function, and a myocardial oxygen supply-demand mismatch. A potential linkage between vascular alterations and the risk of SCD may be related to firefighters' individual characteristics. We have found increased arterial stiffness in a group of obese ( ≥29.5 kg·m −2)
and overweight (25.9 –29.4 kg·m −2) firefighters compared with lean (<25.9 kg·m−2) firefighters, where carotid arteryβ stiff- ness was greatest in the obese group compared with the over- weight and lean groups (5.9 ± 0.3, 5.1 ± 0.3, and 4.9 ± 0.3, respectively) (7). Furthermore, we also have examined vascu- lar changes in older firefighters (40 –60 yr) before and after Volume 44  Number 3  July 2016 Firefighting and Sudden Cardiac Events 93 Copyright © 2016 by the American College of Sports Medicine. Unauthorized reproduction of this article is prohibited.