Impact of stress and stress mindset on prevalence of cardiovascular disease risk factors among first responders

Questionnaire design

Demographic questions related to age, race/ethnicity, sex at birth, and approximate household income were guided by U.S. Census Bureau American Community Survey groupings [27]. Marital status, family history of public service, current first responder position, years of first responder experience, paid versus volunteer, currently smoke or chew tobacco were all developed internally. Marital status categories were (1) Married, (2) Widowed, (3) Divorced, and (4) Not Married. Family history of public service was binary (Yes/No). Current occupation categories were (1) EMT, (2) Paramedic, (3) Firefighter, (4) Firefighter/EMT, (5) Firefighter/Paramedic, (6) Uniformed Police Officer, (7) Non-Uniformed Police Office, (8) Investigator, (9) Uniformed Police Officer/Investigator, (10) Non-Uniformed Police Officer/Investigator, and 11) Other; where participants could specify other as free text. Paid versus volunteer position was a binary variable (Paid/Not Paid). Years of experience categories were (1) Less than 1 year, (2) 1 to 2 years, (3) 3 to 4 years, (4) 5 to 7 years, (5) 8 to 9 years, 6)10 to 11 years, 7) 12 to 14 years, and 8) 15 + years. Currently chew or smoke tobacco was binary (Yes/No).

Presence or absence of any CVD risk factor were based upon Yes/No participant responses to whether they had ever been diagnosed with (1) hypertension (high blood pressure), (2) diabetes, (3) chronic kidney disease, (4) chronic obstructive pulmonary disease (COPD), (5) stroke, (6) hyperlipidemia (high-cholesterol). Presence of a negative stress mindset was captured using the “the effects of stress are negative” question from the Stress Mindset-General instrument validated in previous research [28]. Participants indicating “strong agreement” or “agreement” with “the effects of stress are negative” statement was identified as possessing a negative stress mindset. Previous studies found that the General Stress Mindset questionnaire had a high internal consistency of 0.86 (Cronbach’s alpha) [28]. Briefly, stress mindset is a measure of whether individuals believe that general stress is positive or negative on productivity and well-being [28]. Overall stress within the past week was assessed using the Stress Scale questions from the Depression Anxiety Stress Scale-21 (DASS21) questionnaire [29]. Internal consistency of the previously validated DASS-21 Stress Scale was 0.90 [29]. A copy of the questionnaire instrument is included as Supplemental Files.

Study sample

Individuals over 18 years of age who currently serve as a first responder, defined as either EMS, firefighter, or law enforcement were included in this study. The restriction on individuals across the lifespan was due to limitations associated with the age at which residents can apply for any of the first responder positions listed above. Stress exposures, stress responses, and chronic disease risk factors among junior firefighters and paramedics are likely different than their adult counterparts. The electronic survey was created using ESRI Survey 123 software (30), and data were stored securely on a HIPAA compliant ESRI ArcGIS Enterprise (31) server managed by the West Virginia Clinical and Translational Sciences Institute. Recruitment was conducted from October 31, 2022 to November 15, 2022. Recruitment and survey response collection was done through electronic dissemination through internal list servs for the West Virginia Sheriffs Association (which includes Sherriff’s as well as other local law enforcement), Professional Firefighters of West Virginia Association, and WV Healthnet (includes ground and air EMS transport services). Participants received a 25.00-dollar incentive for completing the survey. The survey instrument was to be completed in one sitting and was estimated to take roughly 15 min to complete. This study was approved by the West Virginia Internal Review Board (protocol # 2210658995).

Statistical analysis

Summary statistics were calculated to visualize mean stress scores and row percentages for demographics and clinical factors for those with stronger stress-is-enhancing mindsets versus those that did not. The DASS-21 Stress Scale for each participant was centered by subtracting the mean from each person’s observed value. This was done to normalize DASS-21 Stress Scales prior to regression. Current positions were dichotomized to identify individuals with multiple first responder roles versus those that did not. This is consistent with previous research that suggests that individuals serving in multiple first responder capacities are at higher risk of a mental health condition [32]. Dichotomizing first responder occupation to multi-job or not, also provides an opportunity to examine multiple functions in the first responder community as an exposure. This is responsive to a need for rigorous research to address first responder needs across the spectrum of occupations [13]. The questionnaire was administered to 156 first responders. This was the limit of funding available for incentives.

Separate linear and logistic regression analyses were conducted to examine the associations between stress, stress mindset, and CVD risk factors included in the study. Variable selection was conducted by calculating chi-square statistics to investigate multicollinearity in categorical predictor variables prior to regression analysis. All statistical analyses were conducted in R [33].