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The responses of a total of 10,649 firefighters were included for analysis, representing approximately 24% of the UK’s total firefighter workforce10. Participant demographics were analysed in Wolffe et al.10, and were not found to significantly differ from the English firefighter population13 with respect to sex (p > 0.05), but appeared to under-represent younger age categories, retained firefighters, and those belonging to an ethnic minority (p < 0.05).
Approximately sixteen percent of firefighters indicated that they believe visible signs of contamination is a BoH, while a further 46% indicated that they believe others hold this attitude (Fig. 1A).
Training on fire contaminants and their associated health outcomes, and belief in the BoH attitude in the UK Fire and Rescue Service. Proportion of total surveyed firefighters who (A) hold/do not hold the BoH attitude, and (B) who have/have not received training on the health effects of fire contaminant exposure.
The majority of firefighters (62%) had not received any training on the health effects of contaminant exposure (Fig. 1B). Of those that had received training, 93% found this training to be useful. Those that had not received training were also receptive to the idea, with 98% indicating that they would find training valuable.
Lack of training only slightly increased the odds ratios for firefighters indicating that they or others believed in the BoH (ORs 1.1, 1.0–1.2, for personal belief in the BoH and 1.1, 1.0–1.2 for others belief). However, this increase was not statistically significant for personal belief in the badge of honour.
Demographics
The Fire and Rescue Services in the United Kingdom are divided into England, Wales, Scotland and Northern Ireland, and each operates under separate legislative and administrative arrangements14. Participant demographics were compared to English FRS statistics13 and presented in Wolffe et al.10. Detailed analysis of the geographic distribution of belief in the BoH/lack of training can be found in Supplemental File S2.
The proportion of firefighters indicating personal belief in the BoH generally increased, and was significantly associated with age (p < 0.05), seniority of role (p < 0.05), and years of service (p < 0.05) (Fig. 2). Managerial firefighters (i.e. crew, watch, station, group, area, and principal managers) were 1.5 times more likely to indicate personal belief in the BoH compared to non-managerial firefighters (OR 1.5, 1.3–1.7). Older firefighters (i.e. those 45 or older) were slightly more likely to indicate personal belief in the BoH compared to younger firefighters (OR 1.2, 1.0–1.3).
Firefighter demographics and belief in the BoH, and training on fire contaminants and their associated health outcomes. (A) The proportion of total surveyed firefighters in each demographic category who personally believe in the BoH, who feel others believe in the BoH, and who have not received any training on the health effects of smoke/contaminant exposure. (B) Crude odds ratios (with 95% confidence intervals) for belief in the BoH attitude/lack of training and demographics. Note that the small sample size for certain demographic groups (e.g. sex = Other, where n = 4), mean that the above proportions should be interpreted cautiously. Participant demographics are summarised in Wolffe et al.10.
Belief in the BoH was significantly more likely in firefighters who had served for more than 5, 10, or 15 years (OR 1.9, 1.6–2.3 for 5+, OR 1.5, 1.3–1.8 for 10+, and OR 1.4, 1.3–1.6 for 15+) when compared to firefighters who had served less than 5, 10 or 15 years respectively. In other words, the association between length of service and belief in the BoH was not diluted by regrouping firefighters into wider length of service categories; indicating that belief in the BoH is spread among firefighters who have served for shorter (5+/10+) and longer (15+) lengths of time. Supported by free text analysis, this indicates that belief in the BoH has only very recently begun to wane, i.e. within the last 0–4 years prior to the survey.
Interestingly, the proportion of firefighters personally believing in the BoH was greatest for those that attend fires on the most and least frequent bases, dipping for firefighters who fall between the two extremes (Fig. 2, although small sample sizes at either extreme warrant caution). Fire attendance frequency was found to be significantly associated with personal belief in the badge of honour (p < 0.05), with firefighters attending fires on at least a weekly basis being 1.2 times more likely to report belief in this attitude than those attending fires less frequently (OR 1.2, 1.1–1.4).
Trends in the number of firefighters who believed that others held the BoH attitude were less clear, with roughly equal proportions of each demographic category indicating that others held the attitude (Fig. 2), and no significant associations found for fire attendance frequency (p > 0.05), or years of service (p > 0.05). However age (p < 0.05) and seniority of role (p < 0.05) were still found to be significantly associated with others’ belief in the badge of honour.
Fire attendance frequency was significantly (p < 0.05) and positively correlated with a lack of training (Fig. 2). Firefighters attending fires at least once a week were 1.2 times more likely to have had no training on fire contaminants compared to those attending fires less frequently (OR 1.2, 1.1–1.3).
Years of service was also found to be significantly associated with lack of training (p < 0.05). Firefighters who had served 15 years or longer were found to be slightly but significantly more likely to indicate that they had not received training compared to those that had served less time (OR 1.3, 1.2–1.4). This was similarly found for firefighters who had served 5 + years (OR 2.1, 1.9–2.4) or 10+ years (OR 1.7, 1.5–1.9). Free text answers also indicated that training on contaminants may only have been introduced in the last 0–4 years before the survey.
A significant association was additionally found between lack of training and age (p < 0.05), but not between lack of training and seniority of role (p > 0.05).
Personal contamination during/after fire incidents
Crude odds ratios for firefighters attending incidents without respiratory protective equipment (RPE) were significantly increased for both belief in the BoH and lack of training on fire contaminants (Fig. 4). Firefighters who personally believed in the BoH, or who had not received training, were both 1.7 times more likely to attend incidents without RPE compared to those who felt nobody believed in the BoH, or who had received training (OR 1.7, 1.5–1.2 and OR 1.7, 1.5–1.9 respectively). Those who felt others believed in the BoH were still more likely to attend incidents without RPE, albeit to a lesser extent than those who personally believed the attitude (OR 1.4, 1.3–1.6).
Culture, awareness and training featured strongly among firefighters’ reasons for attending fires without RPE. Free text responses revealed that firefighters were left to make their own judgements on the use of RPE (14% firefighters providing free text), or felt pressured by peers to attend fires without RPE (7% firefighters providing free text).
Around 4% of firefighters providing free text reasons for attending fire incidents without RPE specifically cited a lack of procedures or poorly enforced procedures concerning when to use RPE, or which RPE was most appropriate to use (Fig. 3). It should be noted that a lack of/poorly enforced procedures are likely to facilitate firefighters being left to make their own judgements on the use of RPE. Thus, while firefighters may not always have mentioned both issues in their free text responses, they are likely to be closely linked.
Culture, awareness and training and attending fires without RPE. Cultural/awareness related reasons for firefighters’ attending fire incidents without respiratory protective equipment, coded from free text. Note that a single firefighter’s free-text answer may have contained several sentiments belonging to several different themes.
Firefighters who believe in the BoH were significantly more likely to eat while wearing PPE (OR 1.8, 1.5–2.2 for personal, and OR 1.4, 1.3–1.6 for others belief in the BoH), Fig. 4. Similarly, a significantly increased odds ratio for eating with sooty hands was found for personal/others belief in the BoH (OR 2.2, 1.9–2.5 for personal, and OR 1.5, 1.4–1.6 for others’ belief in the BoH, respectively). A statistically significant increased odds ratio was also found for staying in PPE for an extended amount of time after attending fire incidents among those who personally believed in the BoH (OR 2.3, 1.4–3.9 for > 4 h). This was not found for firefighters who claimed that others believed in the BoH (Fig. 4).
Crude odds ratios for engaging in behaviours/practices that lead to personal contamination during/after fire incidents for firefighters who believe in the BoH, or who have not received training on fire contaminants and their associated health outcomes.
BoH attitude did not appear to influence the odds ratios for firefighters remaining in their workwear after attending a fire incident (Fig. 4).
Except for remaining in PPE for an extended amount of time after a fire incident, a lack of training was associated with a significantly increased odds ratio for every measure of personal contamination assessed in the survey, i.e. attending fire incidents without wearing RPE (OR 1.7, 1.5–1.9); consuming food with sooty hands (OR 1.8, 1.7–2.0), or while wearing PPE (OR 1.8, 1.6–2.0); smelling smoke on the body after fire incidents (OR 1.3, 1.2–1.4 for a few hours after washing, OR 1.6, 1.4–1.7 for up to a day after, OR 1.6, 1.4–1.8 for more than a day after); and noticing soot in the nose/throat after fire incidents (OR 1.3, 1.2–1.5 until washing, OR 1.7, 1.5–1.9 for a few hours after washing, OR 2.0, 1.7–2.3 for up to a day after, OR 2.3, 1.8–2.8 for more than a day after). Most notably, firefighters who did not receive training were up to 3.6 times more likely to remain in their workwear for an extended amount of time after attending an incident (OR 3.6, 2.3–5.6 for changing workwear at home after finishing a shift, Fig. 4).
For firefighters who believed in the BoH, the odds ratios for both continuing to smell smoke on the body, and for noticing soot in the nose/throat, increased as the length of time after washing on return from an incident increased (Fig. 4). When compared to those who felt nobody believed in the BoH, these firefighters were 2.0 times more likely to smell smoke on their bodies (OR 2.0, 1.6–2.4), and 3.7 times more likely to notice soot in their nose/throat, for more than a day after washing on return from a fire incident (OR 3.7, 2.7–5.2, Fig. 4).These trends were mirrored by firefighters who felt that others believed in the BoH.
Compared to those who felt nobody believed in the BoH, a consistently larger proportion of firefighters who believed in the BoH, or felt their colleagues did, rated face (49% and 38% vs. 36%), neck (32% and 26% vs. 23%), hair (40% and 36% vs. 32%), and hands (54% and 50% vs. 45%) as feeling highly contaminated after fire incidents (Supplemental File S2, Fig. S3).
As expected, a larger proportion of these firefighters also consistently rated hair (65% and 60% vs. 57%) and hands (49% and 43% vs. 38%) as smelling strongly of smoke (Supplemental File S2, Fig. S4). These trends were mirrored for firefighters who had not received training (Supplemental File S2, Figs. S3, S4).
Personal protective equipment
A lack of training and belief in the BoH, were both significantly associated with several negative behaviours/practices concerning the storage and cleaning of PPE (Fig. 5), i.e. those that would put firefighters at a potentially increased risk of contaminant exposure, or would lead to harmful cross contamination.
Belief in the BoH/lack of training and crude odds ratios for engaging in negative PPE storage or cleaning practices. Although the survey asked firefighters whether they sent breathing apparatus and fire gloves for professional cleaning—it should be noted that sending these items for external, professional cleaning is not (currently) standard practice10.
Personal belief in the BoH significantly increased the odds ratios for firefighters never cleaning their PPE (Fig. 5) by as much as 1.9 times (BA never cleaned, OR 1.9, 1.4–2.7). Similarly, belief in the BoH was associated with failing to send PPE for professional cleaning on a regular basis (i.e. sending PPE for professional cleaning less than once per month), although this was only found to be significant for tunics/trousers (OR 1.4, 1.2–1.7) and fire hoods (OR 1.4, 1.2–1.7). Firefighters were also significantly more likely to wear ill-fitting PPE (OR 1.4, 1.1–1.7), and to engage in PPE storage/transport practices known to contribute to cross-contamination if they believed in the BoH. This included taking PPE home to clean (OR 1.4, 1.1–1.6), storing fire gloves within other items of PPE e.g. helmets, boots, tunic pockets etc. (OR 1.2, 1.1–1.4), and failing to store clean/dirty PPE separately (OR 1.5, 1.3–1.7).
Statistical significance was also found for the increased odds ratio associated with firefighters who indicated that their colleagues believed in the BoH sending their PPE for cleaning on an infrequent basis (OR 1.4, 1.1–1.8 for fire gloves, OR 1.2, 1.1–1.0–1.3 for fire hoods, OR 1.2, 1.1–1.3 for tunic/trousers). In addition, a significantly increased odds ratio was found for these firefighters failing to store clean/dirty PPE separately (OR 1.2, 1.1–1.3) and storing used/dirty PPE in the appliance/car cab on return from an incident (OR 1.2, 1.1–1.4). Interestingly, there was no significant association between firefighters who indicated their colleagues believed in the BoH and never cleaning their PPE (Fig. 5).
Lack of training was also associated with a significantly increased odds ratios for all negative PPE storage/cleaning practices assessed in the survey. An exception was for failing to send breathing apparatus (BA) for regular professional cleaning. However, it is not standard practice to send this item for external, professional cleaning (Fig. 5). Notably, a lack of training doubled the odds ratio for firefighters never cleaning BA (professionally or otherwise, OR 2.0, 1.5–2.7), sending fire gloves for professional cleaning infrequently/never (OR 2.0, 1.6–2.4), storing dirty/used PPE in the appliance or vehicle cab on return from incidents (OR 1.8, 1.6–2.0), storing clean and dirty PPE together (i.e. not separately, OR 1.9, 1.8–2.1) and wearing PPE that does not fit well (OR 1.8, 1.5–2.0).
When asked what firefighters’ main reasons for cleaning their PPE were, roughly equal proportions of those from each BoH belief category (i.e. I believe this, others believe this, nobody believes this) selected each of the answer options (Supplementary File S2, Fig. S2). The exceptions were for “I send it after every incident” and “It is damaged”—where a smaller proportion of those who believe in the BoH indicated that these were reasons they would send their PPE for cleaning compared to those who felt nobody believed in the BoH.
A similar trend was observed for training status—whereby a smaller proportion of those who had not received training indicated that they would send their PPE for cleaning after every incident compared to those who had received training (Supplementary File S2, Fig. S2).
Workplace contamination
A statistically significantly larger proportion of firefighters personally holding the BoH attitude indicated that their station had no separate clean/dirty areas (28%) for PPE compared to firefighters who felt others believed in the BoH attitude (22%) (p < 0.05), and compared to firefighters who felt that nobody believed in the BoH attitude (20%) (p < 0.05).
Similarly, a significantly larger proportion of firefighters personally holding the BoH attitude indicated that their workplace smelt of fire/smoke always/most of the time (26%) compared to those who felt that others believed in the BoH (20%) (p < 0.05), and compared to those who felt nobody believed in the BoH (13%) (p < 0.05), Fig. 6.
Belief in the BoH/lack of training and workplace contamination. (A) The proportion of firefighters, and (B) the crude odds ratios, for firefighters in each BoH belief/training status category whose workplaces have no designated clean/dirty areas or smell of fire always/most of the time. *Indicates a p-value of < 0.05 for the z-score test for difference in proportions.
These findings were mirrored for firefighters who had not received training (compared to firefighters who had received training, Fig. 6), i.e. p < 0.05 for the difference in proportions between trained and untrained firefighters whose workplace smells of fire always/most of the time, or whose workplaces have no designated clean/dirty areas.
Firefighters who personally believed in the BoH were found to have odds ratios for smelling fire in the station always/most of the time which were more than twice that of firefighters who felt that nobody believes in the BoH, Fig. 6 (OR 2.3, 2.0–2.6). Firefighters who did not receive any training on fire contaminants were 1.8 times more likely to work in a station without dedicated clean/dirty areas compared to those that had received such training (OR 1.8, 1.6–2.0).
It was also found that firefighters who personally believed in the BoH, or who had not received training on fire contaminants, were over twice as likely to indicate that cleaning was not taken seriously at their workplace compared to those who felt nobody believed in the BoH/had received training (OR 2.5, 2.2–2.9 and OR 2.4, 2.2–2.6, respectively). Firefighters who felt that their colleagues believed in the BoH were also significantly more likely to indicate that cleaning was not taken seriously at their workplace (OR 1.9, 1.7–2.0), albeit to a lesser extent than those who personally held the attitude.
Firefighters were also given the opportunity to provide their thoughts and feelings on the subject of fire contamination at their workplace, via free-text. Around 38% of all firefighters (n = 4072) provided free text responses to this prompt, covering a variety of issues including training provision and culture/awareness. Most notably, 13% of firefighters who answered the question indicated discrepant attitudes toward cleaning and contamination at their workplace, (e.g. “Some people take it seriously, but others don’t”). Approximately, 1% specifically mentioned the BoH, with similarly discrepant views on the demographic of firefighters who hold the attitude (e.g., “Cleaning is not taken seriously by some, mostly new personnel and some experienced personnel. I feel some think it’s a badge of honour to be covered in soot”).
Training also received mention among free text responses. Just 0.2% of firefighters left positive sentiments towards training/awareness. By contrast, 2.4% of firefighters providing free text felt that training/awareness was inadequate, or that further training was required.
Encouragingly, around 9% of firefighters providing free text felt that attitudes/awareness were improving (e.g. “It is getting better with the more we learn”). Many of these firefighters indicated that training had very recently been introduced, or that awareness was only recently increasing. However, many indicated that there was still much work needed to protect firefighters from fire contaminant exposure, or that the pace of change was still slow, e.g. “I can see the new research and findings taking a positive effect on station but it’s not as fast a change as perhaps it needs to be”, “it is only within the last 6 months that it has reached the radar…still a long way to go”).
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