The impact of safety behavior,perceived risk,and workplace resources on COVID outcomes for U.S. Aircraft Rescue and Firefighting personnel

1 Introduction

Respiratory infections continue to be a deadly issue in the United States (U.S.) and globally. During the 2022–2023 and 2023–2024 respiratory virus seasons, there were three co-occurring outbreaks: COVID-19 (caused by the SARS-CoV-2 virus), the seasonal flu, and respiratory syncytial virus (RSV) infection [1]. In the 2022–2023 season, hospitalization rates per 100,000 residents for seasonal flu exceeded five of the 12 past seasons, RSV hospitalizations per 100,000 people exceeded the four previous seasons, and COVID-19 case surges continued [2]. Since the start of the COVID-19 pandemic, there have been over 700 million cases and almost seven million deaths globally, with the U.S. accounting for nearly 1.2 million deaths as of February 2024 [3]. Individuals who have had greater risk for respiratory virus exposures, hospitalizations, and death have been frontline workers, such as those who work in healthcare, public transit, and other industries with essential public-facing roles with close contact with others. Due to the nature of their work, even if wearing a form of respiratory protection, the volume and frequency of exposure to other individuals can make frontline workers highly susceptible to respiratory virus exposure [4–6]. One such worker group is first responders who answer to emergencies of all types, including medical. During a medical emergency where first responders are providing emergency and triage care, a definitive patient diagnosis is often unavailable. Thus, first responders provide care to patients with unknown exposures, symptoms, and variable transmission rates. The three aforementioned respiratory infections—COVID-19, seasonal flu, and RSV—all begin with non-descript influenza-like symptoms (e.g., fatigue, fever, chills) that first responders are potentially exposed to when providing emergency care; yet, they have no way discerning what they were potentially exposed to. Eliminating exposure altogether is not possible for first responders [7]. Thus, individual safety behavior and available workplace resources to prevent potential harmful respiratory exposures and manage the severity to which they will be exposed are of the utmost importance.

Aircraft rescue and firefighting (ARFF) personnel are a type of first responder located at all U.S. airports overseen by the Federal Aviation Administration (FAA) Federal Aviation Regulations (FAR) Part 139 [8]. ARFF are the only civilian fire protection services regulated by a government entity. ARFF duties involve emergency response mitigation, evacuation, and rescue of passengers and crew of aircraft at airports in the event of a fire. ARFF personnel are also responsible for medical response and first aid of anyone present at the airport –not only on the tarmac but also within airport terminals –24 hours a day, 365 days of the year. ARFF personnel are staffed at airports indexed in one of five categories A through E, with A being aircraft less than 90 feet to E being aircraft 200 feet and longer. In addition to airport index categorization, ARFF personnel are staffed based on number of daily departures from that airport. For example, Hartsfield-Jackson Atlanta International Airport, currently the world’s busiest airport, is Index E. With an average of 275,000 passengers per day and an average 2,000 of these passengers are transported to emergency rooms from the Atlanta airport per year for advance medical care that ARFF emergency medical services cannot provide –some of these cases involve passengers experiencing respiratory symptoms or events [9]. Thus, the greater the airport index, the greater the potential for ARFF personnel exposure due to the volume and frequency of close contact with travelers on a regular basis.

While respiratory hazards, such as COVID-19, are not completely avoidable the risk of infection can be mitigated by occupational safety and health (OSH) controls and workplace resources (e.g., via the provision of training, engineering controls, and personal protective equipment (PPE)) and safety behavior. Safety behavior comprises of safety compliance and safety participation. Safety compliance relates to an individual’s compliant behaviors that are consistent with organizational norms, the responsibilities of their position, and specific task requirements. Safety participation is proactive behaviors that contribute to an environment of safety in the organization or workplace [10, 11]. Literature has shown that safety behavior is affected by one’s perceived risk—a combination of perceived severity (i.e., a person’s feelings on the seriousness of contracting an illness or disease) and perceived susceptibility (i.e., a person’s subjective perception of the risk of acquiring an illness or disease); perceived risk and perceived severity are key constructs of the Health Belief Model (HBM) [11–13]. The HBM can be applied in the context of occupational health. According to the HBM, heightened perceived risk is associated with a greater inclination towards cautious behaviors which can reduce the likelihood of adverse health outcomes. COVID-related studies have found higher perceived risk may be related to lower infectivity [14, 15]. To the best of our knowledge, COVID outcomes and factors contributing to COVID infectivity has not been assessed among the essential but overlooked work population of ARFF personnel. Thus, in this study we focused on safety behavior, perceived risk, and workplace resources to understand COVID-19 outcomes during the early pandemic among ARFF personnel. For this study, we hypothesize the following which is also depicted in our conceptual framework (Fig. 1):

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Fig. 1

Hypothesized relationship between positive COVID diagnosis and safety behavior, perceived risk, and workplace resources.

H1: ARFF personnel with high safety behaviors were less likely to have reported COVID-19 infection in the early pandemic.

H2: ARFF personnel with higher perceived risk of COVID-19 were less likely to have reported COVID-19 infection in the early pandemic.

H3: ARFF personnel with access to greater workplace resources were less likely to have reported COVID-19 infection in the early pandemic.

3 Results

Table 1 summarizes the participants’ characteristics of the final study sample (N= 155) and descriptive statistics of the measured variables. Most participants had not tested positive for COVID-19 (n = 129, 83.2%) at the time of survey administration. There were more male participants (n = 143, 92.3%) than females. Most participants were White (n = 124, 80%), middle-aged (n = 64, 41.3% aged 50–59), and had a professional certification (n = 95, 61.3%). The participants’ overall health mean score before the COVID-19 pandemic was 4.36±0.63 along a 5-point scale, indicating good self-reported health. During the COVID-19 pandemic, the participants’ training effectiveness mean score was 4.73±0.03, their resource adequacy mean score was 4.57±0.04, their safety compliance mean score was 4.66±0.04, and their safety participation mean score was 4.23±0.06. While all these scores are on the higher end of a 5-point scale, training effectiveness was the highest. The participants had an average score of 4.20±0.08 for wearing a face mask in the workplace. When the participants were out in public spaces, the mean score for masking was the same as in the workplace, 4.20±0.10. The participants average perceived susceptibility score of COVID-19 was 3.98±0.07, and the perceived severity mean score of COVID-19 was 3.52±0.08. While their perceived susceptibility score was on the higher end of the scale, indicating their perceived risk of contracting the illness or disease, their perceived severity was closer to center of the scale, indicating a less severe perception of the seriousness of the illness or disease.

A correlation matrix was calculated to assess the relationships between the outcome variable (COVID-19 infectivity) and all other measured variables (Table 2). Training effectiveness, resource adequacy, safety compliance, and safety participation were positively correlated with each other (all p’s <  0.01). Specifically, training effectiveness was positive correlated with resource adequacy (r = 0.55), safety compliance (r = 0.43), safety participation (r = 0.27), and mask use at work (r = 0.23), all p’s <  0.01. Resource adequacy was positive correlated with safety compliance (r = 0.46) as well as safety participation (r = 0.39), both p’s <  0.01. Additionally, mask wearing at workplaces, mask wearing in public spaces, safety compliance, and safety participation were positively correlated with each other (all p’s <  0.05). Specifically, the findings indicated a positive correlation between safety compliance and safety participation (r = 0.50), a moderate positive correlation between safety compliance and mask use at work (r = 0.37), and a relatively weaker positive correlation between safety compliance and mask use in public spaces (r = 0.19), all p’s <  0.05. Moreover, a moderate positive correlation between safety participation and mask use at work (r = 0.42), and a relatively weak positive correlation between safety participation and mask use in public spaces (r = 0.26) were found, both p’s <  0.01. Mask use at work also moderately correlated with mask use in public spaces (r = 0.39), p <  0.01.

Additionally, perceived severity was positively correlated with safety participation (r = 0.20), mask-wearing at workplaces (r = 0.26), mask-wearing in public spaces (r = 0.50), and susceptibility (r = 0.21), with all p’s <  0.05. Perceived severity also exhibited a negative correlation with overall health before COVID-19, r = –0.17, p <  0.05. Perceived susceptibility exhibited a positive correlation with COVID-19 outcome, with r = 0.17, p <  0.05.

Table 3 presents the results of hierarchical logistic regressions that assessed factors associated with testing positive for COVID-19 (N= 155). The R-squared increased from 0.03 (Step 1) to 0.12 (Step 4), indicating the proportion of variance explained by the predictors was increasing as more variables were added to the model. Findings from steps 1 to 3 showed that workplace resources (training effectiveness and resource adequacy) and safety behaviors (safety compliance, safety participation, mask use at work, mask use in public spaces) were not significantly associated with COVID-19 outcome (all p’s >  0.05). The last step of regression results showed that each additional unit increase in susceptibility to COVID-19 was associated with a 133% increase in the odds of testing positive for COVID-19 (OR = 2.33, p <  0.05), and with each additional unit increase in perceived severity level, the odds of getting COVID-19 decreased by 47% (OR = 0.53, p <  0.05). Follow-up variance inflation factor (VIF) tests were conducted, revealing no multicollinearity concerns. All VIF values were found to be below the established cutoff point of ten [21].

Aircraft rescue and firefighting (ARFF) personnel have elevated exposures to respiratory hazards due to the nature of their work. In this study—adapting the HBM, as well as Zhang and colleague’s framework on COVID-19 relevant outcomes—safety behavior, perceived risk, and workplace resources were assessed to understand what relationship, if any, it had with COVID-19 outcomes among this specific worker population during the early pandemic [11]. The participants were predominantly white, middle-aged, male ARFF personnel who had not yet tested positive for COVID at the time of survey administration. They reported high levels of training effectiveness, resource adequacy, safety participation, and mask use. We had three main hypotheses for this study: 1) Those with high safety behaviors were less likely to report COVID infection; 2) Those with higher perceived risk of COVID were less likely to have reported COVID infection; and 3) Those with greater workplace resources were less likely to have reported COVID infection. Based on the results from the hierarchical regression, H2 was partially supported given that perceived severity decreased the odds of a positive COVID test. The results of this study have implications beyond the early COVID-19 pandemic that can be applied to OSH considerations for first responder personnel –especially for future large-scale respiratory outbreaks.

The significant finding that emerged from this study pertained to testing positive for COVID-19 and perceived risk, specifically perceived susceptibility and perceived severity. First, perceived susceptibility had a significant positive weight and increased odds ratio with the COVID outcome; in other words, those who perceived themselves to be more susceptible to COVID-19 reported COVID-19 infection. Participants may have had pre-existing conditions or comorbidities—items that were not captured in the scope of this study—that make their immune systems vulnerable to infection, which increased perceived susceptibility [22, 23]. It is estimated that 60% of Americans have at least one comorbidity so it is highly likely ARFF personnel, may also have comorbidities [24]. In a systematic review and meta-analysis of 11 pre-existing comorbidities with COVID-19 mortality, it found that those with cardiovascular disease, hypertensions, diabetes, congestive heart failure, chronic kidney disease, and cancer had greater risk of mortality compared to patients that did not [23]. There could have also been other factors, such as the elevated media coverage of COVID leading to stress [25, 26] resulting in greater allostatic load which can weaken the immune system [27, 28]. Thus, with future inevitable public health outbreaks it may be beneficial for employers to measure (e.g., survey, informal interviews, focus groups) the perceived susceptibility of their employees to the specific “infection/crisis”, to provide workplace accommodation policies [29] and/or heightened training and job-specific prevention measures (detailed below) to decrease overall risk perception.

Second, perceived severity had a significant negative weight and decreased odds ratio with the COVID-19 outcome. In other words, those with greater perceived severity of COVID-19 may have been more likely to take precautions to prevent contracting the virus and thusly did not report COVID-19 infection at the time of survey administration. Several studies on perceived severity and COVID-19 found those with greater perceived severity were more likely to engage in precautionary behaviors and practice greater self-control when it came to public health measures (e.g., isolation, limiting social activities) [30–32]. This is consistent with studies among general populations where elevated perceived harm of COVD-19 outcomes were predictive of safety behaviors [33, 34].

This finding further supports and provides additional evidence regarding the importance of risk messaging during a pandemic or when significant health exposures are present. This not only includes public messaging from public service organizations, but targeted intra-organizational risk communication. Risk messaging should be coherent and targeted [35] so that potential risk severity is understood as perceptions of health risks inform decisions about protective behaviors [36]. Given known challenges with communication across emergency service and fire service organizations [37], risk communication strategies need to be formulated and presented to addresses the unique nature of operations and structure within emergency and fire service organizations. Pollack and colleagues [38] suggest applying behavior change models and using theory to inform the development of messages that can sustain behavior change in these organizations. More specific guidance, including five practical guidelines for effective health and risk communication strategies related to the pandemic and COVID, is presented by Porat and colleagues [39]. These strategies might be translated to intra-organizational interventions or strategies to bolster appraisals of risk in the context of work.

Implications of the findings of the present research potentially extend beyond respiratory illness, such as COVID-19. The importance of risk communication in promoting and fostering protective behaviors is one that needs to be further explored in emergency medical response and fire service organizations. In an occupation that requires frequent exposures to a variety of hazards, it seems that when hazard severity is appropriately appraised, actions to reduce exposures are completed and health consequences are averted. As such, a focus on risk severity within interventions and communication strategies within emergency and fire service organizations may be beneficial in protecting emergency responders and firefighters from injuries.

5 Conclusion

In summary, this study has demonstrated significant associations between the perceived risk factors of COVID-19, which include perceived severity and perceived susceptibility, and the COVID-19 outcome among personnel of ARFF services during the early pandemic. Perceived susceptibility was associated with increased likelihood of COVID-19, but perceived severity was associated with decreased likelihood of reported COVID-19. To formulate effective interventions aimed at safeguarding the wellbeing of first responders engaged in emergency response activities, subsequent investigations should explore the underlying connections between perceived risk factors and COVID-19 outcomes using longitudinal data.

Ethical approval

This study was deemed exempt by the Indiana University Institutional Review Board (Protocol #10518) on March 23, 2021.

Informed consent

Written informed consent was obtained from all study participants prior to the start of the study. No personally identifiable information was presented in this article.