Cardiovascular Disease Prevention in Firefighters

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Title:
Cardiovascular Disease Prevention in Firefighters
Physical Description:
1 online resource (184 p.)
Language:
english
Creator:
Delisle, Anthony Todd
Publisher:
University of Florida
Place of Publication:
Gainesville, Fla.
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Thesis/Dissertation Information

Degree:
Doctorate ( Ph.D.)
Degree Grantor:
University of Florida
Degree Disciplines:
Health and Human Performance, Health Education and Behavior
Committee Chair:
Stopka-Boyd, Christine E
Committee Co-Chair:
Pigg, R. Morgan
Committee Members:
Chaney, Elizabeth H
Tillman, Mark D
Maldonado-Molina, Mildred

Subjects

Subjects / Keywords:
cardiovascular -- disease -- firefighters
Health Education and Behavior -- Dissertations, Academic -- UF
Genre:
Health and Human Performance thesis, Ph.D.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract:
The present research addressed Cardiovascular Disease (CVD), prevention in firefighters, since it contributes to nearly half of all on-duty fatalities and injuries annually. Specifically, this research focused on three integrated studies: 1) To describe the methods used to engage firefighters in the participatory processes of planning, implementing, and evaluating a CVD prevention program utilizing Intervention Mapping (IM) and principles of Community Based Participatory Research (CBPR). 2) To evaluate the validity of the current sub-maximal protocol used to predict the true VO2max of firefighters. 3) To examine the use of a peer-driven firefighter intervention on, improving cardiorespiratory fitness, body composition, and musculoskeletal fitness indicators in high-risk firefighters. The process of integrating principles of CBPR into the steps of IM resulted in the creation of a Community Academic Partnerships comprised of two fire departments, a local public health department, and three health-oriented university academic departments. The integration of CBPR principles with IM proved to be an efficacious and economical approach for engaging firefighters in each phase of the research process, developing an ecological approach to CVD health promotion in firefighters, capitalizing on community capacity; and utilizing iterative system development to guide the research process through mixed-methods evaluations. Currently, a sub-maximal protocol is used to measure cardiorespiratory fitness in firefighters by estimating the true aerobic capacity (VO2max) of firefighters; however, the sub-maximal test has not been validated. Thirty firefighters completed the sub-maximal treadmill protocol and maximal Bruce protocol. Analyses between the sub-maximal and Bruce protocol produced a significant moderate correlation (r=0.635, p = 0.005). The sub-maximal VO2 treadmill test underestimated the true VO2max in the majority of firefighters (72.4%), and overestimated the true VO2max in 24.4% of firefighters. The effects a one year community-based firefighter health intervention has on cardiorespiratory fitness, muscular fitness, and body composition in high-risk firefighters was evaluated. Aerobic capacity significantly increased from baseline to post-testing for the intervention group (p<0.001), while the control group did not significantly increase VO2max (p=0.3838). The control group significantly increased body fat percentages from baseline to post testing (p = 0.044), while the intervention group maintained body fat percentages (p=0.384).
General Note:
In the series University of Florida Digital Collections.
General Note:
Includes vita.
Bibliography:
Includes bibliographical references.
Source of Description:
Description based on online resource; title from PDF title page.
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This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility:
by Anthony Todd Delisle.
Thesis:
Thesis (Ph.D.)--University of Florida, 2012.
Local:
Adviser: Stopka-Boyd, Christine E.
Local:
Co-adviser: Pigg, R. Morgan.
Electronic Access:
RESTRICTED TO UF STUDENTS, STAFF, FACULTY, AND ON-CAMPUS USE UNTIL 2014-08-31

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UFRGP
Rights Management:
Applicable rights reserved.
Classification:
lcc - LD1780 2012
System ID:
UFE0044434:00001


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1 CARDIOVASCULAR DISEASE PREVENTION IN FIREFIGHTERS By TONY DELISLE A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSO PHY UNIVERSITY OF FLORIDA 2012

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2 2012 Tony Delisle

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3 To my mentors, teachers, and students who have supported me throughout this process

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4 ACKNOWLEDGMENTS I would like to acknowledge each of my committee members Dr. Christine Stopka, Dr. Morga n Pigg, Dr. Mark Tillman, Dr. Beth Chaney, Dr. Mildred Maldonado Molina and Dr. Jill Varnes for their guidance, expertise, and support in th ese dissertation research efforts. I would also like to acknowledge the Gainesville Fire & Rescue Department, partic ularly Chief Bill Northcutt, the Peer Fitness Firefighters, firefighter participants in the validation study, to all the firefighters who participat ed in the health program, and for all firefighters who serve and protect the health of our community. I woul d also like to thank all the many research assistants who have participated in this study. I would like to acknowledge my mother Karen father Frank, brother Brian and his wife Tak, and my sister Renee and her family for all their love and support. I would like to acknowledge Pinky Delisle for all his intelligence and mentorship, Snowflake for keeping me on track, Octo for reminding me of the ocean, Bomm ie for his companionship, and Curio and Spaz for reminding me to have fun during this whole process. Fina lly I would like to acknowledge my wife Alexis for incredible support and love through the dissertation research process.

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5 TABLE OF CONTENTS page ACKNOWLEDGMENTS ................................ ................................ ................................ .. 4 LIST OF TABLES ................................ ................................ ................................ ............ 8 LIST OF FIGURES ................................ ................................ ................................ .......... 9 LIST OF ABBREVIATIONS ................................ ................................ ........................... 10 ABSTRACT ................................ ................................ ................................ ................... 11 CHAPTER 1 INTRODUCTION AND LITERATURE REVIEW ................................ ..................... 13 General Introduction ................................ ................................ ............................... 13 Key Terms and Concepts ................................ ................................ ....................... 14 Background and Purpose ................................ ................................ ....................... 16 Prevalence and Incidence of CVD in Firefighters ................................ ................... 20 Risk Factors of CVD in Firefighters ................................ ................................ ......... 21 On duty Task Specific Risk Factors ................................ ................................ 21 Biological Risk Factors for CVD in Firefighters ................................ ................. 23 Smoke and chemical exposure ................................ ................................ .. 23 Cardiorespiratory fitness ................................ ................................ ............ 23 Body mass index and body composition measures ................................ ... 26 Hypertension ................................ ................................ .............................. 27 Lipid profiles ................................ ................................ ............................... 29 Musculoskeletal health indicators ................................ .............................. 29 Summary of CVD risk factors ................................ ................................ ..... 30 Physical Activity as a Protective Factor against CVD ................................ ............. 31 Review of Physical Activity Based Interventions ................................ ..................... 33 Determinants of Physical Activity Behaviors in Firefighters .............................. 34 Interventions in Firefighters ................................ ................................ .............. 35 Interventions in General Popul ation Adults ................................ ....................... 36 Worksite Physical Activity Interventions ................................ ........................... 39 Elements of Efficacious Physical Activity Interventions ................................ .... 40 Limitations of Physical Activity Interventions ................................ ........................... 41 Measurements of Physical Activity ................................ ................................ ... 41 Experimental Design ................................ ................................ ........................ 42 Health Theory and Planning Models ................................ ................................ 42 Representativeness of Sample to Target Population ................................ ....... 43 Sample Size Issues ................................ ................................ .......................... 44 External Validity ................................ ................................ ................................ 45 Program Evaluations ................................ ................................ ........................ 45 Review of Health Theories and Planning Models for PA based Interventions ........ 46

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6 The Ecological Model ................................ ................................ ....................... 48 Individual level factors ................................ ................................ ............... 48 Interpersonal level factors ................................ ................................ .......... 49 Environmental and policy levels ................................ ................................ 49 Common Health Behavior Theories ................................ ................................ 50 Social Cognitive Theory ................................ ................................ .................... 52 Review of Health Planning Models used in Physical Activity Interventions ............. 53 Intervention Mapping ................................ ................................ .............................. 55 Community Based Participato ry Research ................................ ............................. 57 Recommendations for PA Intervention Research in Firefighters ............................ 59 Strengths and Limitations of Proposed Research ................................ ................... 62 Statement of Purpose ................................ ................................ ............................. 68 Significance ................................ ................................ ................................ ............ 69 Research Aims ................................ ................................ ................................ ....... 70 2 METHODS FOR FOSTERING COMMUNITY ACADEMIC PARTNERSHIPS AND UTILIZING INTERVENTION MAPPUNG IN A FIREFIGHTER COMMUNITY ................................ ................................ ................................ .......... 72 Background ................................ ................................ ................................ ............. 72 Methods ................................ ................................ ................................ .................. 76 Formation and Structure of the Community Academic Partnership .................. 76 Selection of CBPR & IM Process ................................ ................................ ..... 77 Results ................................ ................................ ................................ .................... 79 IM Step 1. Needs Assessment ................................ ................................ ......... 80 IM Step 2. Developing Matrices of Change Objectives ................................ .... 83 IM Step 3. Selecting Theory Informed Intervention Methods and Practical Strategies ................................ ................................ ................................ ...... 87 IM Step 4. Producing Program Components and Materials ............................. 91 Department wide PA program ................................ ................................ .... 93 Pi lot intervention for high risk firefighters ................................ ................... 95 IM Step 5. Planning Program Adoption, Implementation, and Sustainability .... 96 IM St ep 6. Planning for Evaluation ................................ ................................ 100 Discussion ................................ ................................ ................................ ............ 105 Limitations ................................ ................................ ................................ ............. 108 3 VALIDATION OF A CARDIORESPIRATORY FITNESS ASSESSMENT IN FIREFIGHTERS ................................ ................................ ................................ ... 114 Background ................................ ................................ ................................ ........... 114 Methods ................................ ................................ ................................ ................ 117 WFI Sub maximal Test ................................ ................................ ................... 119 Bruce Protocol (Maximal VO2 Test) ................................ ............................... 119 Data Analyses ................................ ................................ ................................ ....... 120 Results ................................ ................................ ................................ .................. 121 Discussion ................................ ................................ ................................ ............ 122

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7 4 EFFICACY OF A CARDIOVASCULAR DISEASE INTERV ENTION FOR HIGH RISK FIREFIGHTERS: A PILOT STUDY ................................ ............................. 128 Background ................................ ................................ ................................ ........... 128 Methods ................................ ................................ ................................ ................ 133 Participants ................................ ................................ ................................ ..... 133 Health Measures ................................ ................................ ............................ 134 Peer Mentor Intervention ................................ ................................ ................ 135 Statistical Analysis ................................ ................................ .......................... 137 Results ................................ ................................ ................................ .................. 137 Discussion ................................ ................................ ................................ ............ 139 5 SUMMARY, CONCLUSIONS, RECOMMENDATIONS, AND IMPLICATIONS .... 151 Summary ................................ ................................ ................................ .............. 151 Conclusion ................................ ................................ ................................ ............ 154 Recommendations for Future Research ................................ ............................... 157 Implications ................................ ................................ ................................ ........... 158 APPENDIX A PARTICIPANT INFORMATION ................................ ................................ ............ 161 B WFI SUBMAXIMAL AEROBIC CAPACITY ASSESSMENT ................................ 162 C BRUCE VO 2 MAX ASSESSMENT ................................ ................................ ......... 163 D BRUCE PROTOCOL CHECKLIST ................................ ................................ ....... 165 E PHYSICAL ACTIVITY RECALL SURVEY ................................ ............................ 169 LIST OF REFERENCES ................................ ................................ ............................. 170 BIOGRAPHICAL SKETCH ................................ ................................ .......................... 183

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8 LIST OF TABLES Table page 2 1 Definitions for the principles of community based pa rticipatory research ......... 111 2 2 The steps of Intervention Mapping ................................ ................................ ... 112 2 3 Integrating CBPR principles with Intervention Mapping ste ps .......................... 113 3 1 Descriptive characteristics and health screening information ........................... 126 3 2 Simple statistics: Bruce protocol vs. WFI Sub ma ximal Prediction Tests ......... 126 3 3 WFI Sub maximal P rediction T est compared to Bruce VO 2 max protocol ......... 126 3 4 Correlation of predicto r variables with Bruce VO2max value ............................ 127 4 1 Baseline descriptive measures for department wide, intervention group and comparison group ................................ ................................ ............................. 146 4 2 Baseline equivalence of control and intervention group ................................ ... 146 4 3 Baseline and 3 month post test ................................ ................................ ........ 147 4 4 Baseline to 3 month follow up changes in outcome measures ......................... 148 4 5 Baseline, 3 month, and 1 year follow up mean aerobic capacity values .......... 148 4 6 Long term changes in VO2max in intervention and comparison groups .......... 149 4 7 Between group differences in 1 year mean changes in VO2max ..................... 149

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9 LIST OF FIGURES Figure page 4 1 Measured Aerobic Capacity in Intervention and Comparison Groups ............ 150

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10 LIST OF ABBREVIATION S BF% B ODY F AT P ERCENTAGE BMI B ODY M ASS I NDEX CAP C OMMUNITY A CADEMIC P ARTNERSHIP CBPR C OMMUNITY B ASED P ARTICIPATORY R ESEARCH CRF C ARDIORESPIRATORY F ITNESS CVD C ARDIOVASCULAR D ISEASE EKG E LECTROCARDIOGRAM FFIP F IREFIGHTER F ATALITY I NVESTIGATION P ROGRAM HDL H IGH D ENSITY L IPOPROTEIN HR MAX M AXIMUM H E ART R ATE IM I NTERVENTION M APPING LDL L OW D ENSITY L IPOPROTEIN NIOSH N ATIONAL I NSTITUTE FOR O CCUPATIONAL S AFETY AND H EALTH PA P HYSICAL A CTIVITY PAR% P OPULATION A TTRIBUTABLE R ISK P ERCENTAGE PFT P EER F ITNESS T RAINERS PHLAME P ROMOTING H EALTHY L IFESTYLES : A LTER NATIVE M ODELS E FFECTS RPE R ATE OF P ERCEIVED E XERTION SCT S OCIAL C OGNITIVE T HEORY TTM T RANSTHEORETICAL M ODEL VO 2 MAX M AXIMAL O XYGEN C ONSUMPTION AT THE C ELLULAR L EVEL WFI W ELLNESS AND F ITNESS I NITIATIVE

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11 Abstract of Dissertation Presented to the Graduate Sch ool of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy CARDIOVASCULAR DISEASE PREVENTION IN FIREFIGHTERS By Tony Delisl e August 2012 Chair: Christine Stopka Co chair: Morgan Pigg Major: Health and H uman Performance The present research addressed Cardiovascular Disease (CVD), prevention in firefighters, since it contributes to nearly half of all on duty fatalities and injuries annually. Specifically, this research focused on three integrated studies : 1) T o describe the methods used to engage firefighters in the participatory processes of planning, implementing, and evaluating a CVD prevention program utilizing Intervention Mapping (IM) and principles of Community Based Participatory Research (CBPR). 2 ) To evaluate the validity of the current sub maximal protocol used to predict the true VO2max of firefighters. 3) To examine the use of a peer driven firefighter intervention on, improving cardiorespiratory fitness, body composition, and musculoskeletal f itness indicators in high risk firefighters. The process of integrating principles of CBPR into the steps of IM resulted in the creation of a Community Academic Partnerships comprised of two fire departments, a local public health department, and three he alth oriented university academic departments. The integration of CBPR principles with IM proved to be an efficacious and economical approach for engaging firefighters in each phase of the research process, developing an ecological approach to CVD health p romotion in firefighters,

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12 capitalizing on community capacity; and utilizing iterative system development to guide the research process through mixed methods evaluations. Currently, a sub maximal protocol is used to measure cardiorespiratory fitness in fir efighters by estimating the true aerobic capacity (VO2max) of firefighters; however, the sub maximal test has not been validated. Thirty firefighters completed the sub maximal treadmill protoc ol and maximal Bruce protocol. A nalyses between the sub maximal and Bruce protocol produced a signif icant moderate correlation (r=0.635, p = 0.005). The sub maximal VO2 treadmill test underestimated the true VO2max in the majority of firefighters (72.4%), and over estima ted the true VO2max in 24.4% of firefighters The effects a one year community based firefighter health intervention has on cardiorespiratory fitness, muscular fitness, and body composition in high risk firefighters was evaluated. A erobic capacity significantly increased from baseline to post testing for the intervention group (p <0.001), while the control group did not significantly increase VO2max (p=0.3838). The control group significantly increased body fat percentages from baseline to post testing (p = 0.044), while the intervention group maintained body fat percentages (p=0.384).

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13 CHAPTER 1 INTRODUCTION AND LIT ERATURE REVIEW General Introduction The following section provides a brief background on the description of the problem and significance of cardiovascular disease (CVD) in firefighters; a sta tement of the research purpose for the three articles included in this dissertation; and definitions of key terms and concepts. One million people work in the fire service in the United States. Firefighters provide fire suppression and emergency medical s ervices for 2 million individuals annually, and are a crucial part of public health and safety ( Kales, Soteriades, Christophi, & Christiani, 2007 ) Issues related to the health and safety of firefighters are also a major public health priority, as firefighting is known to be one of the natio n's highest occupational fatality and injury rates ( National Institute for Occupational Safety and Health, 2001 ; United States Fir e Service & National Fire Data Center, 2002 ) What is less widely known is that the most frequent cause of death among firefighters is cardiovascular disease (CVD), rather than burns or smoke inhalation ( Duenas Laita et al ., 2007 ) CVD accounts for 46% of all on duty deaths and disabilities among firefighters annually ( National Institu te for Occupational Safety and Health, 2001 ; Rosenstock & Olsen, 2007 ; United States Fire Service & National Fire Data Center, 2 002 ) In contrast, CVD is responsible for 22% of fatalities in police, 10% in emergency medical service workers, and 11% of all deaths in the general work force ( Maguire, Hunting, Smith, & Levick, 2002 ; National Institute for Occupational Safety and Health, 2001 ; United States Fire Service & National Fire Data Center, 2002 )

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14 Epidemiological studies show a high prevalence of risk factors for CVD among firefighters exists, including: inadequate physical fitness, high rates of obesity, hypertensio n, and unhealthy cholesterol profiles ( Haas, Gochfeld, Robson, & Wartenberg, 2003 ; Kales, Soteriades, & Christoudias, 2003 ; Leiba, Baur, & Kales, 2011 ; Rosenstock & Olsen, 2007 ; Soteriades, Hauser, Kawachi, Chri stiani, & Kales, 2008 ) Even new firefighter recruits are commonly found to be overweight and have low cardiorespiratory fitness ( Kales, et al., 2007 ; Poston et al., 2011 ) Despite the high rates of CVD among firefighters, more than 70% of fire departments lack programs to promote physical fitness and health, do not require firefighters to exercise regularly, or do not require firefighters to undergo periodic medical examinations to screen for CVD risk factors ( Geibe et al., 2008 ) The substantial health and fitness issues facing the fire service have, in large part, not been adequately addressed from the public health research community ( Poston, et al., 2011 ) .Few studies have evaluated interventions for addressing physical fitness, weight gain, high blood pressure, or unhealthy cholesterol in the fire service culture. Innovative studies are needed to determine what types of interventions would be most success ful in improving health and fitness in firefighters. Key Terms and Concepts Community based participatory r esearch (CBPR). Community based participatory research(CBPR) has been identified as a key strategy in effectively reducing health disparities in unde rserved communities ( Pazoki, Nabipour, Seyed nezami, & Imami, 2007 ) CBPR is defined as a collaborative, partnership approach to research that equitably involves, for example, community members, organizational representatives, and researchers in all aspects of the research process.

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15 Partners contrib ute their expertise and share responsibilities and ownership to increase understanding of a given phenomenon, an incorporate the knowledge gained with action to enhance the health and well being of community members ( Israel, Eng, Schulz, & Parker, 2005 ; Pazoki, et al., 2007 ) Intervention Mapping (IM). Intervention Mapping is a protocol for systematically applying theoretical and empirical evidence when designing health promotion programs. PRECEDE/PROCEED model for planning health promotion interventions ( Green & Kreuter, 2005 ) Intervention Mapping includes: conducting a comprehensive needs assessment for t he determinants of a health outcome formulating program objectives for the target group, selecting appropriate theoretical methods, translating methods into practical strategies an ecologically integrated program, conducting development, implementation, im pact, and outcome evaluations ( Bartholomew, Parcel, Kok, & Gottlieb, 2006 ) Ecological m odel The ecological model, as it has evolved in the behavioral sciences and in public health, focuses on the interrelated factors of the individual, interpersonal, community, environment, and policies levels that contribute to health outcomes ( Glanz, Rimer, & Lewis, 2002 ) Physical a ctivity (PA). Physical activity is defined as any bodily movement produced by contraction of skeletal muscle that substantially increases energy expenditure. The dose of physical activity, or exercise, needed to bring about a particular health benefit response is described by the characteristics of frequency, duration, intensity, and type of activity. Frequency descri bes the number of activity

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16 sessions per time period (e.g., day or week). Duration refers to the number of minutes of activity in each session. Intensity describes, in relative or absolute terms, the measured or estimated effort (energy cost) associated wit h the physical activity. Physical activity may be of a leisure time or occupational type activity. Physical fitness is defined as a set of attributes (i.e., cardiorespiratory endurance, skeletal muscle endurance, skeletal muscle strength, etc.) that relate to the ability to perform physical activity ( Haskell et al., 2007 ; Kesanniemi et al., 2001 ) Cardiorespiratory f itne ss. Cardiorespiratory fit ness (CRF), also referred to as aerobic capacity, is defined as the functional ability of the cardiovascular and respiratory system to provide oxygen rich blood to the musculoskeletal system to produce energy for work output over a prolonged period of time CRF is measured in terms of maximal oxygen consumption at the cellular level ( VO 2 max) per kg body weight per minute (mlO2/kg/min). Maximal oxygen consumption is a sensitive indicator of cardiovascular status, and it has important implications for sustain ing dynamic physical work involved in firefighting activities. CRF is shown to be a strong predictor of fatal and nonfatal CVD events in firefighters ( Mier & Gibson, 2004 ; Sui et al., 2007 ) Background and Purpose With one of the highest occupational rate s of fatalities and injuries in the United States, firefighting has earned its reputation as a dangerous profession. What is less widely known is that the most frequent cause of on duty deaths among firefighters is cardiovascular disease (CVD), rather than burns or smoke inhalation ( Duenas Laita, et al., 2007 ) CVD accounts for nearly half of all on duty firefighter fatalities and injuries annually c ompared to just 12% of deaths attributable to asphyxiation (smoke inhalatio n) and 18% to burns and other trauma ( Kales, et al., 2007 ) Despite th is evidence, very

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17 little research and best practice efforts to reduce risk of CVD in firefighters exist. However, recent epidemiological studies ( Rosenstock & Olsen, 2007 ) have identified se veral risk factors regarding: 1) the specific on duty tasks most commonly associated with CVD events and 2) biological based CVD risk factors most commonly associated with CVD events in firefighters. The growing number of studies examining these risk facto rs is producing critical information for guiding interventions aiming to reduce CVD in firefighters. In the past decade, studies have shown the majority of CVD events in firefighters occur when performing strenuous, physically demanding tasks ( Kales, et al., 2007 ; Rosenstock & Olsen, 2007 ) Cohort, longitudinal, and cross sectional studies find several biological indicators, including cardiorespiratory fitness (CRF), Body Mass Index (BMI), hypertension, dyslipidemia, and musculoskeletal fitness relate to CVD events in firefighters ( Baris et al., 2001 ; Haas, et al., 2003 ; Kales, et al., 2007 ; Kales, et al., 2003 ; Soteriades, et al., 2008 ) The considerable physiological demands of firefighting require high levels of cardiovascular endurance and physical fitness many firefighters do no t possess. Promoting health enhancing physical activity is widely advocated by firefighters, researchers, and public health officials to address the issue of CVD in firefighters ( Geibe, et al., 2008 ; Holmer & Gavhed, 2007 ) Physical Activity (PA) is well documented as an important preventive factor in the prevention of CVD ( Haskell, et al., 2007 ; Kesanniemi, et al., 2001 ) Regular PA can help firefighters safely meet the strenuous physical de mands of the on duty tasks commonly linked to CVD events. Additionally, PA can help to improve the biological risk factors associated with CVD in firefighters.

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18 Consistent PA is shown to in increase cardiorespiratory fitness, mediate healthy weight manageme nt, reduce high blood pressure, increase healthy cholesterol while decreasing unhealthy cholesterol levels, and increase musculoskeletal fitness indicators ( Sassen, Kok, Schallma, Kiers, & Vanhees, 2010 ) Despite the calls to increase PA to reduce CVD in firefighters, there is little evidence based research on the efficacy or effectiveness of such efforts. In addition to the lack of research, more than 70% of fire departments lack any best practice program to promote physical activity. Further, most fire departments do not require firefighters to exercise regularly, or undergo periodic medical and fitness examinations ( Kales, et al., 20 07 ) Unlike other occupations, firefighters have a distinctive work schedule and environment, in which they typically work 24 hour shifts during which they cook, eat, exercise and sleep at the fire station. Culturally, the work environment is distinguish ed by close social ties (known as brotherhood), primarily male population (nationwide average 96% male) ( Hulett, Bendick, Thomas, & Moccio, 2008 ) and machismo ( Staley, 2008 ) This unique culture and work environment of firefighters precludes the need to e xamine the research on promoting PA in comparable populations in this particular worksite setting, to inform similar efforts in firefighters. Decades of research examining the determinants of PA behaviors and the effectiveness of interventions to promote P A has contributed to meaningful advances in theoretical understandings of PA behaviors, and has also produced important implications for undertaking health planning efforts to reduce CVD in firefighters via PA. Community driven socio ecological approaches for PA based health promotion interventions are now widely recommended by leading researchers to reduce health

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19 disparities. The ecological model, as it has evolved in the behavioral sciences and in public health, focuses on the reciprocal transactions of factors at the individual, interpersonal, community, environmental, and policy levels governing PA health behavior. Utilizing community driven ecological models to promote PA in firefighters may be useful due to the unique cultural characteristics, persona l traits, social dynamics, env ironmental influences, and para military work structure that are inherent in the firefighter profession. The purpose of this research is to develop an evidence based health promotion program to improve CVD risk factors in firef ighters. This chapter presents a review of the relevant literature. This chapter details the prevalence of CVD in firefighters, describes risk factors associated with CVD in firefighters, examines the evidence of PA as protective factor against CVD, and su mmarizes the major findings and limitations of interventions promoting PA in firefighters and in the general population. The final section of this chapter proposes specific theory driven models and best practice strategies for developing, implementing, and evaluating a PA based CVD prevention program for firefighters. Chapters 2 4 describe three inter related manuscripts based on these aims and strategies. The first manuscript describes the methods used to engage firefighters in the participatory processes of Community Based Participatory Research and Intervention Mapping (IM). This manuscript describes methodologies used in planning, implementing, and evaluating of a CVD intervention. The second manuscript evaluates the validity of a Cardiorespiratory Fitne ss ( VO 2 max ), assessment used to measure the aerobic fitness of firefighters. The final manuscript will describe the implementation and evaluation a pilot CVD prevention program for firefighters. Finally,

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20 Chapter 5 of this dissertation proposal will present a synthesized conclusion of the strengths and limitations of the proposed studies. The proposed studies are among the first efforts to describe the participatory process of community driven health promotion research in firefighters, validate the current c ardio respiratory fitness assessment used to assess aerobic capacity of firefighters, and use theory driven ecological strategies to intervene on risk of CVD in firefighters. Prevalence and Incidence of CVD in Firefighters Cardiovascular Disease accounts for 46% of all on duty deaths and disabilities among firefighters annually ( National Institute for Occupational Safet y and Health, 2001 ; Rosenstock & Olsen, 2007 ; United States Fire Service & National Fire Data Center, 2002 ) In contrast, CVD is responsible for 22% of fatalities in police, 10% in emergency medical service workers, and 11% of all deaths in the general work force ( Maguire, et al., 2002 ; National Institute for Occupational Safety and Health, 2001 ; United States Fire Service & National Fire Data Center, 2002 ) The disparity of CVD in the firefighter profession raises many questions about the contributing factors as it has become a major public health priority among public health officials and leading researchers ( Kales, et al., 2007 ; MacKinnon et al., 2010 ; Poston, et al., 2011 ) Emerging evidence from both government led commissions and epidemiological researchers has identified several risk factors associated with CVD in firefighter concerning specific on duty tasks and biological based CVD risk factors ( Duenas Laita, et al., 2007 ; Leiba, et al., 2011 ; National Institute for Occupational Safety and Health, 2001 ; Poston, et al., 2011 ; United States Fire Service & Nation al Fire Data Center, 2002 ) The National Institute for Occupational Safety and Health (NIOSH),

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21 commissioned the Firefighter Fatality Investigation Program (FFIP), to examine summaries of all on duty deaths and disabilities due to CVD in firefighters from 1994 2006 provided by the Federal Emergency Management Agency. The studies conducted by the FFIP were largely limited to descriptive, case series and case reports of on duty fatalities without control conditions or other means of comparative analysis. The se designs are limited because they cannot statistically associate specific occupational and personal risk factors with increased CVD risks. Therefore, many epidemiological researchers undertook internal, case control study designs by pooling publicly avai lable NIOSH reports of individual on duty CVD firefighting fatalities to elucidate specific on duty tasks and underlying biological risk factors for CVD in firefighters ( Fahy, 2005 ; Kales, et al., 2007 ; Maguire, et al., 2002 ) This is a recommended method for occupational CVD studies as it controls for confounding var iables related to non occupational risk factors for heart disease ( Steenland, 1996 ) Despite the difference in statistical analysis and research design, the FFIP report and the majority of epidemiolo gical studies produced similar findings regarding risk for CVD in firefighters. The following section provides a review these findings in terms of the task specific and the biologically based risk factors most commonly associated with CVD in firefighters. Risk Factors of CVD in Firefighters On duty Task Specific Risk Factors Estimates of the proportion of time firefighters spent performing various duties related to CVD were obtained from a municipal fire department, from 17 large metropolitan fire departmen ts, and from a national database ( Kales, et al., 2007 ; United States Fire Service & National Fire Data Center, 2002 ) Statistical risk of CVD by on

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22 duty activities have been categorized into specific professional firefighting activities including; fire suppres sion, alarm response, physically demanding non fire emergencies, physical training, and non physically demanding duties ( National Institute for Occupational Safety and Health, 2001 ) Fire suppre ssion tasks involve lifting heavy equipment, demolition of physical structures to access fire, operating active water hoes to extinguish fires, and include search and rescue operations in fires. Physically demanding non fire emergencies include medical bas ed rescues and can involve extrication, heavy lifting of persons and/or equipment, and administration of continuous life support. Physical training includes any type of simulated emergency training, any job related physical fitness activities, and physical abilities testing. Non physically demanding duties include administrative and fire station tasks, fire prevention education, inspection, maintenance, meetings, parades, and other public relations activities ( National Institute for Occupational Safety and Health, 2001 ; United States Fire Service & National Fire Data Center, 2002 ) The majority of CVD deaths and disabilities in fire fighters occur during activities requiring strenuous bouts of physical exertion; suppressing a fire (36%), performing physically demanding non emergency duties (15%), responding to an alarm (13%), engaging in physical training (12%) ( Geibe, et al., 2008 ; National Institute for Occupational Safety and Health, 2001 ; Rossi, 2003 ; United States Fire Service & National Fire Data Center, 2002 ) Firefighters are least likely to experience a CVD event when p erforming non physically demanding duties, as they account for only 10% of the total activities linked CVD in firefighters ( Duenas Laita, et al., 2007 ; Glendhill & Jamnik, 1992 ; S. N. Kales, et al., 2007 ) I n contrast of the odds of death from CVD during duties

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23 involving little physical demands, the odds wer e 12.1 to 13.6 times as high during fire suppression, 2.8 to 14.1 times as high during alarm response, 2.2 to 10.5 times as high during physically demanding non fire emergencies, and 2.9 to 6.6times as high during physical training ( Burgess et al., 2001 ; Kales, et al., 2007 ; Rosenstock & Olsen, 2007 ; D. L. Smith, Manning, & Petruzzello, 2001 ) Biological Risk Factors for CVD in Firefighters The following section reviews the findings of studies examining various biologically plausible risk factors associated with fatal and nonfatal CVD events in firefighters and include: cardiorespiratory fitness, Body Mass Index and other body composition measures, hypertension, lipid profiles, and general physical fitness indicators ( Friel & Stones, 1992 ; Guidotti, 1992 ; Kales, et al., 2007 ; Melius, 2001 ; Poston, et al., 2011 ; D. L. Smith, et al., 2001 ; Soteriades, et al., 2008 ) Smoke and chemical exposure Research shows there is a weak relationship between smoke and chemical exposure and CVD events in firefighters ( Geibe, et al., 2008 ; Kales, et al., 2007 ; United States Fire Service & National Fire Data Center, 2002 ) Investigators assert this is most likely due to the w idespread use of self contained breathing apparatus that nearly eliminates all exposure to carbon monoxide, particles, and other toxins from being inhaled ( Butcher, Mayne, Jones, Hartley, & Peterson, 2007 ) Cardiorespiratory fitness The majority of fatal and non fatal CVD events in firefighters occur during prolonged bouts of strenuous exertion under the stress of heat ( Burgess, et al., 2001 ; Geibe, et al., 2008 ) During these circumstances, firefighters work at near maximal heart rates for prolonged periods of time under the stress of extreme temperatures and using

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24 heavy equipment ( Rossi, 2003 ) Heat stress and fluid loss during the conditions CVD events occur in firefighters is believed to be the result of a decreases in cardiac output despite sustained tachycardia ( Reichelt & Conrad, 1995 ) Subsequently, the relationship between the fitness of the cardiovascular and respiratory systems has received considerable attention regarding CVD in firefighters ( Glendhill & Jamnik, 1992 ; Holmer & Gavhed, 2007 ; Poston, et al., 2011 ) Cardiorespiratory fitness, also referred to as aerobic capacity, is defined as the functional ability of the cardiovascular and respiratory system to deliver oxygen rich blood to the musculoskeletal system to produce energy for work output over an prolo nged period of time ( Rosenstock & Olsen, 2007 ) CRF is measured in terms of maximal oxygen consumption, or VO 2 max Maximal oxygen consumption ( VO 2 max ), is a sensitive indicator of cardiovasc ular status, and it has important implications for sustaining dynamic physical work, and is also linked to the ability to sustain work in a hot environment ( Mier & Gibson, 2004 ; Sothmann et al., 1990 ) An increasing volume of literature implicates low cardior espiratory fitness as a major modifiable risk factor for premature mortality and morbidity due to CVD ( Donovan et al., 2009 ) In fact, research is showing CRF may be the most important biological factor for CVD ( Murphy, Bond, Beaton, Murphy, & Johnson, 2002 ) as it is shown to be a stronger predictor of fatal and nonfatal CVD in firefighters than obesity, which is already significantly associated with CVD ( Harvey, Kraemer, Sharratt, & Hughson, 2008 ; P. N. Peterson et al., 2008 ; Poston, et al., 2011 ) A longitudinal cohort design study, controlling for BMI, found individuals who could not achieve 85% predicted cardiorespiratory capacity had significantly more fatal and nonfatal myocardial

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25 infarctions, unstable angina, and hypertension than those who could achieve 85% predicted cardiorespiratory capacity ( Harvey, et al., 2008 ; Peterson, et al., 2008 ) This finding is consistent with investigations implicating low CRF levels as a strong triggering factor for CVD, e specially among physically inactive persons ( Poston, et al., 2011 ; Sui, LaMonte, & Blair, 2006 ; Sui, et al., 2007 ) Rates of low CRF are highly prevalent among the firefighter population ( Mier & Gibson, 2004 ; Rhea, Alvar, & Gray, 2004 ) Studies show 25% of firefighters fail to achieve a generally accepted minimum cardiorespiratory fitness level of 42.0 mlO 2 /kg/min ( Harvey, et al., 2008 ) Levels of cardiorespiratory fitness are also highly associated with the presence of other biological based CVD risk factors such as hypert ension, cholesterol, and obesity ( Haskell, et al., 2007 ; Kesanniemi, et al., 2001 ) This association has important implications for interven tion efforts for promoting CRF as practical and economic way to intervene on multiple CVD risk factors simultaneously ( MacKinnon, et al., 2010 ) Surprisingly, m any fire departments do not require firefighters to exercise regularly ( Kales, et al., 2007 ; Kales, et al., 2003 ) Therefore, researchers, public health officials, and concerned firefighters recommend all fire departments should consider incorporating annual fitness evaluations, exe rcise guidance and minimum fitness standards as part of a comprehensive cardiovascular disease risk reduction strategy in this occupational group ( Kales, et al., 2007 ; MacKinnon, et al., 2010 ; National Institute for Occupational Safety and Health, 2001 ) Results of t his review suggest stress tests for persons in physically demanding occupations, such as firefighting, is strongly recommended ( Geibe, et al., 2008 ; Mier & Gibson, 2004 ) An abnormal CRF exercise test can be an important prognostic

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26 indicator, especially when combined with the presence of other CVD risk factors su ch as elevated blood pressure ( Sui, et al., 2007 ) A recent prospective study of over 25,000 asymptomatic men demonstrated that abnormal CRF exercise tests are highly predictive of subsequent cardiac death, and the association increases for each addit ional risk factor present ( Haskell, et al., 2007 ; Swain & Franklin, 2006 ) No clear guidelines exist, however, for stress testing in asymptomatic individuals, even for public safety professionals such as firefighters ( Harvey, et al., 2008 ) Further research is needed to determine the most appropriate and effective strategy for exercise testing ( Mier & Gibso n, 2004 ; Swain & Franklin, 2006 ) Body m ass i ndex and b ody c omposition m easures Substantial research shows being categorized as being overweight or obese Body related to rates of mortality and morbidity due to CVD ( Kesanniemi, et al., 2001 ; Soteriades, et al., 2008 ) Results from the FFIP report found that 90% of all CVD fatalities occurred in firefighters who were either classified as being overweight or obese ranges ( United States Fire Service & National Fire Data Center, 2002 ) Firefighters with high BMIs demonstrate impaired cardiovascular function, are more likely to exhibit high risk CVD profiles, and have substantially lower cardiorespiratory fitness and physical activity levels than their non obese counterparts ( Kales, Polyhronopoulos, Aldrich, Leitao, & Chr istiani, 1999 ; Poston, et al., 2011 ; Soteriades, et al., 2008 ) The association of elevated BMI and CVD in firefighters is concerning because nati onally representative longitudinal studies examining the rates of obesity among firefighter populations are producing alarming distributions of BMI ( Poston, et al., 2011 ; Soteriades, et al., 2008 ; Soteriades et al., 2005 ) Several studies found prevalence

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27 rates of firefighters being classified as either b eing overweight or obese exceeds those rates seen in the U.S. general population of adults, even after standardizing for age in order to facilitate comparison estimates ( Flegal, Carroll, Ogden, & Curtin, 2010 ) Further research shows prevalence rates between 75 88% of firefighters classified as being either overweight or obese, compared to 66% in the ge neral population ( Haskell, et al., 2007 ; Mancuso, 2003 ; Pos ton, et al., 2011 ) The mean BMI of firefighter populations is reported to be between 29.0 29.7 kg/m, slightly below the obesity classification of a obese, 2.5% are ( Clark, Rene, Theurer, & Marshall, 2002 ; Fahs, Smith, & Horn, 2009 ; Yoo & Franke, 2009 ) This research is counterintuitive to what many health professionals believe because firefighting is not considered to be a s edentary profession. These finding confirm additional research showing rates of obesity are high in firefighters regardless of how obesity was measured ( Fahs, et al., 2009 ; Poston, et al., 2011 ; Tsismenakis et al., 2009 ) Body Fat percentages (BF%), calculated by skin folds protocols, and waist circumference have also been used to measure rates of obesity in firefighters ( Poston, et al., 2011 ) The highest estimates for obesity prevalence rates are found when using BF% skin fold measures. It is worth noting BF% is widely considered to have gr eater validity than other obesity measures such as BMI ( Haskell, et al., 2007 ; Rubiano, Nunez, & Heymsfield, 2000 ) Hypertension significant and strong predictor of on duty CVD events in firefighters ( Geibe, et al.,

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28 2008 ; National Institute for Occupational Safety and Health, 2001 ; Soteriades et al., 2002 ; United States Fire Service & National Fire Data Center, 2002 ) Firefighters meeting hypertensive criteria are 3.8 times more likely to suffer a CVD event than firefighters who are not hypertensive ( Fahs, et al., 2009 ; Geibe, et al., 2008 ) An investigation found 56% of the autopsies performed on firefighters dying from CVD had evidence of left ventricular hypertrophy ( Poston, et al., 2011 ) a sign of high blood pressure that also significantly increases the risk of arrhythmia and is a strong predictor of cardiovascular mortality ( Benjamin & Levy, 1999 ; Haider, Larson, Benjamin, & Levy, 1998 ) The association of high blood pressure and CVD events is alarming when considering rates of hypertension in firefighters are known to be very high ( Geibe, et al., 2008 ; Kay, Lund, Taylor, & Herbold, 2001 ; Soteriades, et al., 2002 ; Yoo & Franke, 2009 ) Dr. Adi Leiba from Harvard Medical School recently presented the results of a study to the American Society of Hypertension 2011 Scientific Meeting showing 30% of fi refighters had elevated blood pressure levels, placing them at increased risk of cardiovascular events ( Leiba, et al., 2011 ) These findings are consistent with other research showing one third of firefighters have high blood pressure ( Geibe, et al., 2008 ; Kales, et al., 2007 ; Poston, et al., 2011 ; Yoo & Franke, 2009 ) Investigators attribute uncontrolled hypertension to the association for case fatality rates of CVD in f irefighters, since studies show high blood pressure is often untreated in the majority of hypertensive firefighters ( Poston, et al., 2011 ; Soteriades, et al., 2005 ) Hypertensive firefighters experience an excessive blood pressure response to physical exertion, and tend to be less physically fit than firefighters who have a normal blood

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29 press ure response ( Leiba, et al., 2011 ) Therefore, researchers believe in addition to periodic blood pressure screenings, fire departments should promote aggressive risk factor reduction strategies, such as promoting PA, to control for the high rates of hypertension in firefighters. Lipid p rofiles The high prevalence of elevated total cholesterol among firefighters is well documented ( Friel & Stones, 1992 ; Kales, et al., 2003 ; Rhea, et al., 2004 ; Soteriades, et al., 2005 ) A first of its kind prospective cohort study examining lipid panels among firefighters found pervasive and abnormally high total Low Density Lipoprotein cholesterol levels (LDL), and abnorm ally low High Density Lipoprotein levels among firefighters at baseline and during follow up ( Ide, 2000 ; Rosens tock & Olsen, 2007 ; Soteriades, et al., 2005 ; Soteriades, et al., 2002 ) High total cholesterol, high LDL, and low HDL are significant predict ors of CVD incidents in firefighters and in the general population ( Guidotti, 1995 ; Kales, et al., 2003 ; Soteriades, et al., 2002 ) The high prevalence of elevated total cholesterol in firefighters, along with its known relationship to CVD, strongly support suggestions by leading researchers to include lipid p rofiles in annual medical examinations, along with prevention and treatment programs addressing unhealthy cholesterol levels in firefighters ( Kales, et al., 2003 ; National Fire Protection Association, 2000 ; Soteriades, et al., 2002 ) Musculoskeletal h ealth i ndicators Evidence sup porting the health benefits of activities that increase muscular strength and muscular endurance has accumulated rapidly in recent years ( Braith & Stewart, 2006 ; Haskell, et al., 2007 ; Pollock, Franklin, Balady, & AHA Science Advisory Committee, 2000 ) Recent observational studies have suggested an inverse asso ciation

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30 between risk of all cause mortality from CVD and other chronic disease with various components of muscular strength or endurance ( Fitzgerald et al., 200 4 ; Haskell, et al., 2007 ; Katzmarzyk & Craig, 2002 ; Poston, et al., 2011 ) Musculoskeletal PA promote the development and maintenance of metabolically active lean muscle mass, which is particularly important for enhancing glucose metabolism ( Ivy, Zderic, & Fogt, 1999 ; Jurca et al., 2005 ) The emerging evidence on musculoskeletal health benefit s ( Haskell, et al., 2007 ; Pollock, et al., 2000 ) illustrates the need for promoting muscular fitness to support efforts to reduce CVD in firefighters. Many incumbent firefighters lack the minimum exercise tolerance thought necessary to safely perform the mo st demanding tasks ( Donovan, et al., 2009 ; Leiba, et al., 2011 ; Poston, et al., 2011 ) Even new firefighter recruits are overweight and have low to normal aerobic capacities ( Clark, et al., 2002 ) Surprisingly, most fire departments do not require firefighters to exercise regularly ( S. N. Kales, et al., 2007 ; Poston, et al., 2011 ) According to the 2008 International Association of Firefighters report concerning the fire service Joint Labor Management Wellness and Fitness Initiative ; few fire departments require veterans to maintain the physical standards required of new hires, most firefighters do not receive medical examinations, or are required to participate in on duty PA and fitness activities ( International Association of Firefighters, 2009 ) Summary of CVD risk f actors To summarize, firefighters are most likely to experience CVD while performing physically demanding tasks. Bio logically based CVD factors, namely CRF, obesity, high blood pressure, unhealthy cholesterol levels, and poor musculoskeletal fitness are all interrelated and significantly increase the risk for CVD in firefighters ( Lakka et al., 2002 ; Sassen, Kok, et al., 2010 ) The results of these studies suggest that comprehensive

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31 preventive programs are needed to address CVD risk factors in firefighters. Inve stigators of these studies universally recommend regular PA and exercise as a critical component for reducing CVD in firefighters. Physical Activity as a Protective Factor against CVD The following section presents the evidence for PA as a protective fact or for CVD risk factors mentioned in the previous section. First, a brief overview of the common terminology used in the health sciences regarding the aspects of physical activity is provided. It is well documented that regular PA has a positive health i mpact on each of the biological CVD risk factors ( Berlin & Colditz, 1990 ; Nocon et al., 2008 ; Sofi, Capalbo, Cesari, Abbate, & Gensini, 2008 ) Additionally, regular PA can help firefighters develop the physical fitness required to safely meet the strenuous physical demands of the on duty tasks most commonly linked to CVD events. In addition to the favorable impact PA has on the task specific and biological risk factors, PA is a low cost, feasible, safe therapy with minimal adverse side effects ( Elliot et al., 2007 ) The prevalence an d incidence rates of mortality and morbidity due to lack of PA are alarming. Lack of physical activity and is now considered the second leading cause of preventable death in the United States ( Antikainen & Ellis, 2011 ; Myers et al., 2002 ; Wannamethee & Shaper, 2001 ) Physical inactivity is a leading contr ibutor to morbidity and disability, accounting for 22% of coronary heart disease, 22% of colon cancer, 18% of osteoporotic fractures, 12% of diabetes and hypertension, and 5% of breast cancer ( Mokdad, Marks, Stroup, & Gerberding, 2004 ; Myers, et al., 2002 ; Nocon, et al., 2008 ) The calculation of a Population Att ributable Risk percentage (PAR%) provides a useful estimate of the burden of a particular disease or condition attributable to a given

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32 exposure in this case, the percentage of specific mortality or morbidity that is attributable to physical inactivity. Usi ng this approach, it has been estimated that the PAR% of cardiovascular disease mortality due to physical inactivity is approximately 35% ( Kesanniemi, et al., 2001 ) According to Mokdad ( Mokdad, et al., 2004 ) who authored Actual Causes of Death yearly incidence rates of death from 1990 2000 due to physical inactivity increased faster than deat h rates attributable to smoking. Annual death rates attributed to smoking increased from 400,000 in 1990 to 435,000 in 2000 (an increase of 35,000 deaths). Annual deaths rates attributed to physical inactivity grew from 1000,000 in 1990 to 165,000 in 2000 (a net increase of 65,000 deaths) ( Mokdad, et al., 2004 ) In other words, the yearly incidence rates of death due to physic al inactivity were nearly double the rates of death due to smoking (65,000 vs. 35,000 respectively). Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in the developed world ( Farag et al., 2010 ; Ign arro, Balestrieri, & Napoli, 2007 ) The top two indicators are physical activity and overweight/obesity. Lack of physical activity has been shown to be a strong independent risk factor for death from coronary heart disease ( Mokdad, et al., 2004 ; Myers, et al., 2002 ) Conversely, those who are physically active have a reduced risk of developing CVD ( Bauman, 2004 ; President's Council on Physical Fitness and Sports, 2002 ) In a meta analysis, Berlin and Coditz ( Berlin & Colditz, 1990 ; Pazoki, et al., 2007 ) calculated a 1.9 fold increased relative risk for CVD mortality associated with a sedentary lifestyle compared with a vigorously active lifestyle. Cross sectional studies have found associations between physical activity and a number of health related variables, including blood pressure, high density

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33 lipoprotein cholesterol, and obesity ( Haskell, et al., 2007 ; Kesanniemi, et al., 2001 ; Pazoki, et al., 2007 ) Cardiorespirator y fitness, lipid/lipoprotein profiles, blood pressure, postprandial lipidemia, and weight control, all appear to be affected beneficially with intermittent bouts of physical activity ( Donnelly, Jacobsen, Heelan Snyder, Seip, & Smith, 2000 ; Haskell, et al., 2007 ; Kesanniemi, et al., 2001 ; Murphy, et al., 2002 ; Sui, et al., 2007 ) New science has added to our understanding of the biological mechanisms by which physical activity provides health benefits and in te rms of the dosage of the physical activity performed (type, intensity, amount) and that is associated with enhanced health and quality of life ( Haskell, et al., 2007 ; Kesanniemi, et al., 2001 ) Economic costs are associated with physical inactivity levels in addition to the health impact, physical inactivity accounts for about 2.4% of U.S. health care costs, or approximately $24 billion a year ( Pratt, Macera, & Wang, 2000 ) Review of Physical Activity Based Interventions The following section provides a background on determinants of physical activ ity in firefighters, background on previous evidence based efforts to promote physical activity in firefighters, a review physical activity based intervention efforts in comparable populations (adults), a review of work site physical activity interventions and provides a summary of the key elements for physical activity based intervention efforts to help inform future health promotion efforts to reduce CVD in firefighters. Given the substantial research linking the health benefits of PA to improved aerobic capacity, blood pressure, lipid profiles, and body composition in firefighters and the general population, investigators assert successful physical activity behavioral changes in is a critical component to reduce CVD risk factors ( Donnelly, et al., 2000 ;

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34 Elliot, et al., 2007 ; Haskell, et al., 2007 ; Kales, et al., 2007 ; Kesanniemi, et al., 2001 ; Murphy, et al., 2002 ; Soteriades, et al., 2005 ; Sui, et al., 2007 ) However, limited research exists on intervention efforts to adequately promote regular aerobic PA to reduce risk factors related to CVD in firefigh ters ( Elliot, et al., 2007 ; Kales, et al., 2003 ) The need for efficacious and effective evidence based health pr omotion efforts are now becoming a major public health priority given the disproportionately high rates of CVD deaths, disabilities, and risk factors in firefighter populations has remained unchanged over the past decades ( Geibe, et al., 2008 ; Poston, et al., 2011 ) Researchers and public health officials are calling for the development of theory driven ec ological models targeting the multiple levels of interrelated factors that were identified and reviewed in the previous section ( Biddle & Nigg, 2000 ; Booth, Owen, Bauman, Clavisi, & Leslie, 2000 ; Owen, Leslie, Salmon, & Fotheringham, 2000 ) Theory driven ecological models have important applications for firefighter s because of the unique work structure inherent in the firefighter profession ( McLeroy, Bibeau, Steckler, & Glanz, 1988 ; Peterson & Aldana, 1999 ) Unlike traditional professions, firefighters are characterized by unique individual traits inherent to their profession, rely heavily upon the social dynamics of team work, are present in the work environments for longer periods of time (24 hour shifts), and are governed by paramilitary style institutional policies of job performance, conduct, and behavior ( Elliot, et al., 2007 ) Determinants of P hysical Activity Behaviors in Firefighters Little research has examined the unique socio cultural and normative factors influencing firefighter health behaviors, especially regarding the factors contributing to PA behaviors and overall fitness in the firef ighter culture ( Elliot, et al., 2007 ; Poston, et al., 2011 ) To date, studies specifically examining the unique determinants of PA in

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35 firefighters is nearly nonexistent. The literature is so sparse that it is uncertain if PA and physical fitness is a core value held by t he majority of firefighters The only research related specifically to determinants of PA behavior comes from a dissertation on ascertaining factors that facilitate overall firefighter physical fitness and the cultural meaning of physical fitness. This stu dy was guided by a social ecological framework and provides significant insights to assist health promotion efforts and fire departments to improve the effectiveness of workplace fitness programs, and change the culture of fitness and low coronary risk sal ience. Interventions in Firefighters Few studies have evaluated interventions for promoting PA, addressing obesity, and other physical fitness in the fire service culture. The only known evidence based interventions to date, PHLAME (Promoting Healthy Lifes Effects), is a prospective randomized control trial among 599 firefighters in the northwest region of the United States ( Elliot, et al., 2007 ) Many researchers and practitioners regard this study as a logical starting point for further inquiry into evidence based efforts to implement effective, easily exportable, and economically feasible health promotion interventions to reduce CVD in firefighters. The objective of PHLAME was to assess and compare two strategies to promote healthy lifestyles in firefighters. Firefighters were randomized by fire station into either a team centered curriculum, or to an individual based curriculum or into control conditions. Assessment included physical activity, card iorespiratory fitness, BMI, nutrition, and general well being at baseline and 12 months. The team and MI programs did not increase physical activity levels or cardiorespiratory fitness compared to the

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36 control group. However, both treatment groups experienc ed significantly less weight gain and significantly increased fruit and vegetable consumption ( Elliot, et al., 2007 ) Although PA and aerobic capacity was not significantly affected, this study provides important insights in to future PA based intervention efforts. Elliot and colleagues uncovered several lessons in regards to working within the firefighter culture and unique work structure. First the authors found team centered and individual level paradigms are both effective strategies for delivering health programs to firefighters. The authors reported high participation rates, low attrition rates, high fidelity, and sufficient reach of both strategies. Elliot suggest future research is recommended to assess a mix method des igns utilizing both individual and team centered strategies to address the broader range factors in the firefighter culture influencing health behaviors ( Elliot, et al., 2007 ) More innovative studies are needed to determi ne what types of interventions would be most successful in improving health and fitness in firefighters ( Poston, et al., 2011 ) Due to the sparse evidence for PA based health promotion efforts in firefighters, it is necessary to examine the known determinants of PA and to review PA based intervention efforts in demographically comparable populations and in similar settings. Extrapolating findings from this research is critical for the development, implementation, and evaluation of future eff orts to reduce CVD in firefighters. Interventions in General Population Adults The process promoting PA involves a multitude of complex variables, including personal, programmatic, social, environmental and related factors. To achieve long term changes in health related PA behaviors, these factors must be addressed collectively ( Sallis, Kraft, & Linton, 2002 ) As oppose d to traditional PA interventions targeting one

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37 level of influence, the strategies of efficacious PA interventions target multiple levels of influence including individual, interpersonal, community, environmental, and/or policy factors simultaneously. Inte rvening on multiple levels of influence grew out of research demonstrating social and environmental barriers contributing to inhibiting physical activity participation even among the most motivated persons ( Kahn et al., 2002 ; Sallis, et al., 2002 ) Results from earlier PA based interventions generally report little success, with hig h rates of recidivism of participants to previous levels of pre intervention inactivity, especially if the duration of the program extended beyond several months ( O'Neal & Blair, 2001 ; Oldridge, Ragowski, & Gottlieb, 1992 ; Oldridge & Steiner, 1990 ; Sassen, Kok, et al., 2010 ) It is frequently reported that 50% of sedentary adults who begin an PA or exercise program will drop out within 6 months, and that 80 90% will drop out within one year ( Antikainen & Ellis, 2011 ; Haskell, et al., 2007 ) Evidence from four meta analyses of RCTs shows physical activity interventions produce short term moderate changes in self reported physical activity (the odds ratio for achieving increased PA ranged from 1.2 to 1.3 in treatment groups), and cardio respiratory fitness on an average of only 6 months before participants return to pre interven tion levels ( Foster, Hillsdon, & Thorogood, 2005 ; Galani & Schneider, 2007 ; Greaves et al., 2011 ) These studies are supported by lower quality evidence from six meta analyses of RCTs, and from three systematic reviews, that interventions only sustain an increase of self reported physical activity of an average o f up 6 weeks to 19 months of follow up ( Douketis, Macie, Thabane, & Williamson, 2005 ; Eakin, Glasgow, & Riley, 2000 ; Greaves, et al., 2011 ; Norris et al., 2007 )

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38 Interventions with an explicitly stated theoretical basis such as Social Cognitive Theory ( Bandura, 1986 ) or Theory of Planned Behavior ( Azjen, 1991 ) were more effective in producing changes in either weight or in physical activity outcomes ( Antikainen & Ellis, 2011 ; Greaves, et al., 2011 ) Four meta regression analyses (all medi um quality associative analyses) in two reviews ( Dombrowski et al., 2000 ; Michie, Abraham, Whittington, McAteer, & Gupta, 2009 ) did find an association between the use of a theoretically specified cluste (specific goal setting, prompting self monitoring, providing feedback on performance, goal review) and increased effectiveness in terms of weight loss and change in physical activity outcomes. The limited long term success of these interventions is largely believed to be due to only intervening on one of the multiple levels of influence for contributing to PA behaviors ( Antikainen & Ellis, 2011 ; Greaves, et al., 2011 ; Kok, Schaalma, Ruiter, van Empelen, & Brug, 2004 ) For example, the majority of PA interventions in the level of influence and were primarily ba sed on educational strategies. Although the results from some recent interventions have been encouraging, the psychological physiological, social, community, environmental, and policy based factors influencing the adoption of a physically active require additional research ( Kahn, et al., 2002 ; Klem, Wing, Lang, McGuire, & Hill, 2000 ; Lee, Blair, & Jackson, 1999 ; I. M. Lee & Skerrett, 2001 ) Future efforts to promote physical activity must cons ider how people interact with their social and environment influences ( Heath et al., 2006 )

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39 Worksite Physical Activity Interventions The workplace is an important social environment that influences health behavior by its norms, policies, and job characteristics ( Murphy, et al., 2002 ; Wilson, Holman, & Hammock, 1996 ) One occupational group with a relatively unique work and social environment is that of professional firefighters ( Corneil, 1995 ; Elliot, et al., 2007 ) In most U.S. cities, firefighters have become the first responders t o medical emergencies and rely on teamwork in both fire suppression and medical emergencies. Employees who engage in teamwork are more likely to spend off duty time together than those whose jobs require more independence ( Fillmore, 1992 ) The Department of Health and Human Services report to the Surgeon General, and the Center for Disease Control and Prevention Health People national objectives for public health in the United Stat es, have targeted worksites as important settings for interventions to increase physical activity. Worksites offer unique opportunities to encourage adults and their families to increase levels of physical activity. Most adults spend half their waking hou rs at the workplace ( Murphy, et al. 2002 ) Hence, exposure to mass reach approaches and behavioral interventions potentially can be more substantial than in many other community settings ( Dishman, Oldenburg, O'Neal, & Shephard, 1998 ) Researchers cite many reasons for the limited evidence of effective worksite health promotion interventions to increase physical activity and healthy nutrition, and to reduce CVD risk factors. Quantitative synthesis of the literature indicates most interventions are not theory driven and lack evidence based principles of behavior modification ( Kahn, et al., 2002 ; Pignone, Ammerman, & Fernandez, 2003 ) While it is widely believed multi level influences (individual traits, social dynamics, environmental

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40 factors, and institutional policies) play an essential role in health behaviors ( French, Story, & Jeffery, 2001 ; Stokols, 1996 ) relatively few interventions systematically intervene upon or assess the impact these influences have on health outcomes ( Glanz, et al., 2002 ) Studies show most health intervention efforts are not designed to simultaneously address the broad range of influe nces over the performance of health behaviors. Additionally, most interventions lack rigorous experimental design, implementation protocols, and objective measures for intervention effects ( Kahn, et al., 2002 ) Elements of Efficacious Physical Activity Interventions Future efforts to promote physical activity must consider how individuals interact with their social and environment influences ( Sassen, Gerjo, Schaalma, Kiers, & Vanhees, 2010 ) Multip le level strategies for increasing PA in adults include individually tailoring behavioral modification techniques, fostering social supports, developing community capacity to support PA, providing environmental prompts to be PA, and implementing policies p romoting PA in the workplace ( Booth, et al., 2000 ; Sallis, et al., 2002 ) Many of the activities developed for each the multiple levels of influence focus on overcoming barriers to PA. Individually tailored efforts included motivational techniques, addressing personal interests, needs, a nd schedules. Interpersonal intervention efforts largely address dynamics of social influences from family, friends, and co workers. Providing access to PA supportive environments and alternatives for PA opportunities during inclement weather and when trav eling ( Haskell, et al., 2007 )

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41 Limitations of Physical Activity Interventions Despite widespread attempts t o target worksites as a setting for interventions to promote increased physical fitness and healthy nutritional practices, there is little attention given to the firefighter profession ( Elliot, et al., 2007 ) Subsequently, t here is limited scientific evidence supporting an effective approach for interventions promoting health behavioral changes to reduce physiological CVD risk factors in firefighters. Furthermore, findings from several systematic scientific reviews of univers al worksite interventions show most do not adequately promote physical activity behaviors, or reduce risk factors associated with CVD in participants ( Dishman, et al., 1998 ) Understanding the many limitations of evidence based and best practices to promote PA is critical for the continued efforts to develop, implement, and evaluate health promotion research. The follow ing sections reviews the limitations of current PA research regarding measurements, research design, use of health theory, applying health planning models, and threat to external validity. Measurements of Physical Activity Studies collectively did a poor job of measuring physical activity, relying mainly on non validated self reports of physical activity and submaximal estimates of VO 2 max, which can be influenced by learning, habituation, or motivation to perform. Several of the studies that used submaxima l estimates of VO 2 max failed to habituate their subjects; this led to large apparent gains of fitness in control groups or, in the absence of a control group, to spurious gains of fitness in the experimental group. The problem of measurement of physical ac tivity is not unique to worksite interventions. Questions about the validity of self reported physical activity are illustrated by one study in which a

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42 subgroup of the intervention condition reported a 20% increase in physical activity, but VO 2 max decrease d by 6% ( Dishman, et al., 1998 ) Experimental Design Most interventions lack rigorous experimental design, implemen tation protocols, and objective measures for intervention effects ( Kahn, et al., 2002 ) Many of the studies did not adhere to either an expe rimental or quasi experimental design that included control groups. Most studies also relied solely on self reported measures rather than more objective measures such as physiological based indicators. Another limitation in some studies was a lack of outco me results and the amount of impact they had on individual behavior ( Matson Koffman, Brownstein, Neiner, & Greaney, 2005 ) Dishman and colleagues ( Dishman, et al., 1998 ) developed a multiple linear regression model including with the key moderating variables for PA intervention effectiveness and found research design had the only independent influence on the size of intervention effects. The quasi experimental design studies yielded larger effects sizes compared with randomized experimental designs. Dishman asserts this may reflect difficulties in organizing and execu ting a well designed and large scale are noted in previous review articles. Health Theory and Planning Models A quantitative synthesis of the literature ( Pignone, et al., 2003 ) indicates most interventions are not theory driven, lack evidence based principles of behavior modification, and rarely report of utilizing a planning model for health programming ( Kahn, et al., 2002 ) Researchers cite man y reasons for the limited evidence of effective PA health promotion interventions to increase physical activity and to reduce CVD risk

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43 factors. While it is widely believed multi level influences (individual traits, social dynamics, environmental factors, a nd institutional policies) play an essential role in health behaviors ( French, et al., 2001 ; Stokols, 1996 ) relatively few interventions systematically intervene upon or assess the impact these influences have on healt h outcomes ( Glanz, et al., 2002 ) Antikainen and colleagues conducted an extensive review on PA interventions and found the vast majority targeted individual levels only, most whic h had small effects sizes and insignificant results on PA outcomes ( Antikainen & Ellis, 2011 ) This is consistent with other reviews and research showing th e limitations on individual only efforts to promote health, underscoring the need to intervene on multiple levels simultaneously. The majority of conceptual models used in PA research only target one level of the ecological perspective, mainly the individ ual or community level. There have been limited attempts to develop approaches that target multiple levels of analysis and can stimulate basic and applied research. Epstein and Matson Koffman found few studies of policy and environmental interventions to increase physical activity ( Epstein, 19 98 ; Matson Koffman, et al., 2005 ) These types of intervention efforts are relatively new public health paradigms for increasing physical activity. Further research is needed to evaluate the adde d value of policy and environmental interventions with and without more traditional individual educational and community messaging interventions. Representativeness of S ample to T arget P opulation The facet of reach is important for determining public hea lth impact and appropriateness of a program for translational research. The representativeness of the study participants to the target population is critical in generalizability. Unfortunately, only a few physical activity interventions reviewed in this li terature review reported on

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44 the representativeness of the participants to the target population. Future researchers should report the characteristics of their participants as compared with the whole target population and determine if demographic difference s exist in intervention efficacy. Reporting on inclusion and exclusion criteria in the target population is rare in the literature. The practical importance of reporting inclusion criteria and exclusion rate for translational research is twofold. First, re searchers need to know who was excluded to determine if the results can be generalized to a potential population and setting, and second, researchers need to know how many people were excluded based on these standards to determine the feasibility of the in tervention for a given target population ( Antikainen & Ellis, 2011 ) Future researchers should consider the impact a strict focus on internal validity has on the external validity of their study as they provide limited information for practitioners looking to implement the intervention in real world settings where such factors cannot be controlled. Sample Size I ssues Antikainen and colleagues ( Antikainen & Ellis, 2011 ) found in their RE AIM evaluation of theory based PA interventions widespread difficulties in recruiting adequate numbers of participants or havi ng limited resources to include large samples are additional factors that impact the results and efficacy of intervention studies. In the studies Antikainen and colleagues reviewed, sample sizes ranged from 20 to 2087 with a median sample size of 126. In a ddition, 35.2% of the studies had less than 100 participants. However, Antikainen and colleagues defended the lack of large sample sizes in the research they reviewed by asserting the focus should not necessarily be on recruiting large numbers of people fo r a single intervention, because in real world

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45 settings few programs or organizations have the funding to reach thousands of people. These researchers suggest future studies, need to focus on program evaluations of intervention protocol, results, and effec ts of interventions rather than focus only on the efficacy of a single program. This would provide the information needed for future reviews and meta analyses to determine the actual public health impact and efficacy of interventions. Shifting focus in thi s manner would also encourage the publication of studies that are well designed and described and can be translated to real world settings, but that may lack statistically significant findings because of a small sample size ( Antikainen & Ellis, 2011 ) External Validity Antikainen and colleagues conducted the first study to review the external validity and translatability of theory based physical activity int erventions targeting various populations ( Antikainen & Ellis, 2011 ) The physical activity interventions included in this review were much more likely to re port on issues of internal, rather than external validity. The practical implication of this is that the translation of many of the interventions into practice would be difficult or impossible. In addition, most studies included motivated, healthy particip ants reducing the generalizability of the interventions to real world settings that provide services to diverse populations. Program Evaluations Only a few of the interventions in this literature review reported any information on process evaluation. Seve ral explanations for this lack of reporting have been proposed by Antikainen et al. and include: 1) The complexity and time consuming nature of current behavior change programs is largely believed to cause investigators to forgo either conducting process e valuations, or to not report on them. 2) The space limitations

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46 of most scientific journals have led to brief descriptions of programs and a lack of reporting on process evaluation ( Antikainen & Ellis, 2011 ) If the intervention was not delivered as originally intended, the reader should be made aware of the changes that took place so they can evaluate the effectiveness of the program based on the actual proce ss rather than a description of an ideal scenario. Process evaluation data can also provide practitioners with information about how flexible a given program is to changes while still maintaining efficacy. Expanded descriptions of the interventions would allow readers to better understand their scope and complexity, the strategies used to establish them, and what they could accomplish. When evaluating reach of an intervention, few studies reported t he intended target population. Future researchers should i dentify a specific target population and report the number of people targeted to provide other researchers or practitioners the ability to evaluate the potential reach of an intervention ( Antikainen & Ellis, 2011 ) Review of Health Theories and Planning Models for PA based Interventions This section reviews the health behavior theories and health promotion planning models most commonly used to predict, explai n, and intervene on the determinants of PA presented in the previous section. Interventions showing significant increases in long term PA and physical fitness incorporated distinct systematic theory driven strategies and techniques during the recruitment, screening, and intervention phases of programs. Theories and the use of health planning models are extremely important for developing effective interventions. When translating theoretical methods into practical strategies, planners have to consider the the oretical parameters very carefully. Examples of adequate theory application include the Ecological Model, Social Cognitive

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47 Theory (SCT), and using the health planning model Intervention Mapping (IM). The Ecological Model, SCT, and the IM planning model wil l be described in the following section since they have been empirically shown to be effective and maybe particularly useful in health programs for firefighters. This section concludes with a review on the use of Community Based Participatory Research and Intervention Mapping to promote regular PA, and is proposed as efficacious approaches for use in firefighter communities. A health promotion program is most likely to benefit participants and communities when it is guided by social and behavioral science theories of health behavior and health behavior change ( Eakin, et al., 20 00 ; Michie, et al., 2009 ) Long term changes in individual and group PA behaviors are frequently accompanied by theories and the use of planning models to guide the development, implementation, refineme nt, and evaluation of interventions ( Greaves, et al., 2011 ) Effective theory driven PA health promotion programs require the operational and practical applications that are tailored to the target population ( Glanz, et al., 2002 ) Research ers and public health officials are calling for the development of theory driven ecological models targeting the multiple levels of interrelated factors that were identified and reviewed in the previous section ( Biddle & Nigg, 2000 ; Booth, et al., 2000 ; Owen, et al., 2000 ) Theory driven ecological models have impo rtant applications for firefighters because of the unique work structure inherent in the firefighter profession ( McLeroy, et al., 1988 ; T. R. Peterson & Aldana, 1999 ) Unlike traditional professions, firefighters are characterized by unique individual traits inherent to their profession, rely heavily upon the social dynamics of team work, are p resent in the work environments

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48 for longer periods of time (24 hour shifts), and are governed by paramilitary style institutional policies of job performance, conduct, and behavior ( Melius, 2001 ; National Institute for Occupational Safety and Health, 2001 ) The Ecological Model The ecological model, as it has evolved in the behavioral sciences and in public health, focuses on the interrelated factors of the individual, interpersonal, community, environment, and policies levels that cont ribute to PA health behaviors. A number of recen t studies suggest ecological models may help to increase PA and enhance physical fitness activities ( Baker, Brennan, Brownson, & Houseman, 2000 ; Bartholomew, et al., 2006 ) Research indicates several determinants exist at each level of the ecological model that are responsible for participation in PA and promotion of physical fitness ( Owen, et al., 2000 ; Reniscow, 1997 ; Sallis, Prochaska, & Taylor, 2000 ) These findi ngs are providing insight towards integrating the most relevant health behavior theory at each level of the ecological model ( Glanz, et al., 2002 ) The following sections include a brief overview of the determining factors associated with PA behavior in adults within each of th e levels of the ecological model. Individual level factors Personal factors such as, age, gender, ethnicity, education al level, socio economic status and various personal traits are shown to significantly influence PA behaviors in adults. Research shows P A levels tend to decrease as age increases, males are more likely to be PA than females; white people are more physically active than other ethnicities; more educated adults are likely to be physically active; adults of higher socioeconomic status are more likely to be physically active than those of lower socioeconomic status ( Owen, et al., 2000 ; Reniscow, 1997 ; Sallis, et al., 2000 )

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49 Personal traits have received the most attention in health promotion research as it is widely considered to be the most modifiable of the individual level factors related to PA behavior. Personal traits, particularly motivation, behavioral skills, and self efficacy are significantly related to PA behaviors in adults. Research shows adults who are motivated intrinsically, who have the behavioral capability to be proficient in PA, and who demonstrate moderate to high self efficacy are more likely to engage in PA. These participating in PA ( Owen, et al., 2000 ; Reniscow, 1997 ; Sallis, et al., 2000 ) Interpersonal level factors Both quantitative (cross sectional and longitudinal) and qualitative studies show the importance of social support in enhancing physical activity ( Baker, et al., 2000 ; Bartholomew, et al., 2006 ) Social variables that are associated with physical activity include; social context of surroundings in which many people were exercising, having friends who encouraged exercise, and having at least 1 friend with wh om to exercise. Among interpersonal factors influencing PA behaviors, social support for exercise from family, friends, or exercise program staff is the most clearly established determinants ( Ba ker, et al., 2000 ; Bartholomew, et al., 2006 ) Social support can be direct and tangible (e.g., providing a non driver with a ride to an exercise class), or informational (sharing information about physical activity and encouraging a friend to participate). Environmental and p olicy l evels A systematic literature of the effects for modifying environmental and policy worksite levels of influence can improve physical activity and fitness ( Matson Koffman, et al., 2005 ) Matson Koffman and colleagues found that nearly all of the 10 studies meeting the inclusion criteria for their review addressing environmental and policy

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50 factors related to PA demonstrated positive effects on pa Matson Koffman et al. found worksite intervention efforts that utilized on site exercise equipment and facilities had a positive effect on participants' cholesterol levels and systolic blood pressure, fitness levels and freque ncy of self reported exercise. One study showed that creating a work environment supportive of physical activity increased employees' levels of physical activity. Another study showed that organizational policy support for exercise increased significantly after human resource managers attended training on building and developing a wellness committee. Post intervention results yielded excellent improvements in administrative support for worksite resources to promote on duty physical activity. Three intervent ions at worksites created environmental modifications by providing changing facilities to increase physical activity among employees. A study of one of these interventions showed that installing locker rooms led to an increase in the number of employees wa lking or bicycling to work. Two of the worksite intervention studies showed that providing counseling and health promotion activities (e.g., organized physical fitness activities or health education classes), was more effective in increasing employees' phy sical fitness than providing staffed on site exercise facilities alone ( Matson Koffman, et al., 2005 ) Common Health Behavior Theories Research based on the various theories that have been applied in attempts to explain human be havior has its roots in classical learning theories. The most commonly used health theories include the Health Belief Model, Transtheoretical Model, Social Cognitive Theory, Theory of Planned Behavior, and the ecological perspectives ( Azjen, 1991 ; Bandura, 1986 ; Biddle & Nigg, 2000 ; Oldridge & Steiner, 1990 ) All of these theories have been used successfully in physical activity interventions ( Antikainen &

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51 Ellis, 2011 ; Glanz, et al., 2002 ) Researchers suggest the use of many theories is needed to match the unique characteristics within the multiple levels of the ecological model influencing PA behavior, (individual, interpersonal, community, environmental).To design more effective interventions, researchers suggest using several theories, building the intervention around several mediators, and measuring the change in theory based mediators ( Kok, et al., 2004 ) However, multiple theory approaches have most likely led to the mixed results from experimental or quasi experimental research makes it difficult to determine the effectiveness of any single theory or model ( Seefeldt, Malina, & Clark, 2002 ) Although there are inconsistencies in the existing data, several characteristics are common to the various theories and models To be effective, in dividual needs, personal level of fitness, readiness for a change in PA behavior, personal confidence in PA and its expected outcome, social support from family, peers, and community seem to promote adherence to physical activity in structured and free liv ing situations ( Seefeldt, et al., 2002 ) To date, the Transtheoretical Model (TTM) demonstrates the highest efficacy at the individual level of behavior for physi cal fitness ( Marshall & Biddle, 2001 ) Social Cognitive Theory (SCT) is demonstrating the most promise for effectivel y intervening on the social, environmental, and institutional policy levels ( Booth, et al., 2000 ) engaging in physical activity and nutritional health behavior ( Marcus & Le wis, 2003 ; Marshall & Biddle, 2001 ; T. R. Peterson & Aldana, 1999 ) The TTM assesses an and assigns the individual into one of five Stages of Change: pre contemplation stage, contemplation stage, planning

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52 stage, action stage, or maintenance stage. The TTM then customizes several Process of Change strategies based upon the individuals specifi c Stage of Change to induce the performance of a health behavior ( Prochaska & Velicer, 1997 ) Social Cognitive Theory Studies show Social Cognitive Theory ( SCT) holds promise for the development of effective health worksite interventions targeting the social, environmental, and institutional policy levels ( Booth, et al. 2000 ; Conn, 1998 ; Kim, Kim, Park, & Kim, 2009 ; Sheeshka, Woolcott, & Mackinnon, 1993 ) SCT propose s that the reciprocal interactions a critical role in the performance of health behaviors ( Bandura, 1986 ) SCT rati onalizes that social factors such as peer influences, role modeling of behaviors, and vicarious learning are significant mechanisms involved in physical activity ( S eefeldt, et al., 2002 ) Firefighters are required to work with one another as one unit for nearly all of their time spent performing on duty tasks. Therefore, SCT will play an even more profound role in health behaviors of firefighters due to the team ce ntered interactions inherent in the firefighter population ( Elliot, et al., 2007 ) One of the strongest determinants emerging from social cognitive theory is self efficacy as it has been consistently been reported as positiv ely associated with physical activity in adults ( Conn, 1998 ) adherence to structured programs, and in those with injuries or disabilities ( Seef eldt, et al., 2002 ) Research has shown 23% of the variance in physical fitness could be predicted by self efficacy for physical active behavior, and has been shown to be a mediator for the intensity of physical activity performed. ( Seefeldt, et al., 2002 ) Additionally, social cognitive variables are useful predictors of physical active behavior and of the intention to engage in physical activity for 60

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53 minutes every day ( Kim, et al., 2009 ) Social cognitive variables accounted for 52% of the variance in physical active behavior and 39% of the variance in intention to engage in physical activity ( Fallon, Wilcox, & Ainsworth, 2005 ) A review of the literature showed that social cognit ive variables accounted for 27% of the variance in behavior and 39% of the variance in intention ( Kim, et al., 2009 ) SCT also acc ounts for the environmental influences of health behavior ( Bandura, 1997 ) These include factors that are external to th e individual. Firefighters work in the fire station environment for most of their 24 hour shift. Fire stations typically have access to physical fitness equipment. The environmental work structure of the typical fire station provides universal access to re sources that can be utilized to promote physical activity behaviors through SCT applications. The external influence of policies governing firefighter behavior in the work environment has a significant impact on health behaviors ( Glanz, et al., 2002 ) Exercise programs are not required by all fire departments. However, firefighters from fire departments that do require physical training demonstrate higher rates of overall physical activity levels when compared to firefighters from fire departments that do not require physical tr aining ( D. Smith, 2011 ) The paramilitary style of policies regarding job performance, conduct, individual behavior, and team work predisposes the firefighter profession as a fully capable o rganization to institutionalize health related policies ( Elliot, et al., 2007 ) Review of Health Planning Models used in Physical Activity Interventions As mentioned earlier in this literature review, adequate application of behavioral science theories is essential for effective behavior change interventions, therefore planning and evaluation are key elements in developing health promotion programs. Theories and empirical evidence form the basis for decisions during the plann ing

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54 process, by helping to answer questions about the problem, the behavioral and environmental factors involved the determinants of behavior, the objectives of the program, appropriate methods and strategies, program implementation and evaluation ( Kok, et al., 2004 ) In practice, however, applying theories for interventions is rather difficult ( Green & Kreuter, 2005 ) f established, well defined behavior change techniques are associated with increased effectiveness, and should be ( Greaves, et al., 2011 ) Therefore, a planned ap proach to intervention design is recommended, and utilizing a health planning model to guide theoretical applications, such as PRECEDE PROCEED or Intervention Mapping, is essential to address targeted behavior change processes that are tailored for the tar get population and setting of interest ( Greaves, et al., 2011 ; McEachan, Lawton, Jackson, Conner, & Lunt, 2008 ) Health promotion is a planned activity ( Kok, et al., 2004 ) A widely used health PRECEDE/PROCEED model (Green & Kreuter, 1999). The PRECEDE model starts with analyses of quality of life, health, behavior and environmental factors, and predisposing, reinforcing and enabling dete rminants (correlates) of behavior and environmental factors. In PROCEED a health promotion intervention is developed, implemented and evaluated. The options for a useful program evaluation depend on the quality of program planning. Rossi, Freeman and Lipse y argue that it would be a waste of time, effort and resources to estimate the impact of a program that lacks measurable goals or that has not been implemented in a proper way ( Rossi, 2003 )

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55 Intervention Mapping Evidence based health promotion programs are founded on empirical data and theory. While a broad range of social and behavioral science theories are available, the actual application of these theories in program design remains a real challenge for health promotion planners ( Kok, et al., 2004 ) Intervention Mapping describes a protocol for the development of theory and evidence based health promotion programs. It provid es guidelines and tools for the selection of theoretical foundations and underpinnings of health promotion ( Bartholomew, et al., 2006 ) Intervention Mapping is a protocol for systematically applying theoretical and empirical evidence when desi gning health promotion programs. Intervention Mapping for planning health promotion interventions ( Green & Kreuter, 2005 ) Intervention Mapping includes: conducting a comprehensive needs assessment for the determinants of a health outco me formulating program objectives for the target group, selecting appropriate theoretical methods, translating methods into practical strategies an ecologically integrated program, conducting development, implementation, impact, and outcome evaluations ( Bartholomew, et al., 2006 ) Intervention Mapping provides a protocol for selecting and applying theories that may improve our understanding of health behaviors and health behavior change ( Bartholomew, et al., 2006 ) Intervention Ma pping describes the process of health promotion program development in six steps: (1) needs assessment (2) the definition of proximal program objectives based upon scientific analyses of health determinants; (3) the selection of theory based intervention m ethods and practical strategies to change determinants of health related behavior; (4) the production of program components,

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56 design and production; (5) the anticipation of program adoption, implementation and sustainability; and (6) the anticipation of pro cess and effect evaluation. Intervention developing theory and evidence based health promotion. It maps the path from recognition of a need or problem to the identific ation of a solution. Although Intervention Mapping is presented as a series of steps, the planning process is iterative rather than linear ( Bartholomew, et al., 2006 ) Intervention Mapping guarantees that: (1) each program objective is grounde d on empirical evidence and theory; (2) the final materials and activities are linked both with theory and have clearly specified objectives; (3) all important objectives are covered; (4) the program is compatible with the target population; and (5) diffus ion issues are anticipated throughout the process ( Kok, et al., 2004 ) It can be argued that the st rengths of Intervention Mapping also represent its weaknesses. ( McEachan, et al., 2008 ) T he theory and evidence based intervention development of IM is a complex and time consuming process ( Kok, et al., 2004 ) Needs assessments, creation of the matrices of change objectives, performance objectives, and the process of evaluations is particularly time consuming ( Bartholomew, et al., 2006 ) McEachan et al. comment that the interve ntion mapping protocol is typically applied to simple and uni dimensional behaviors, and can become overwhelming when applied to multi dimensional behaviors, such as physical activity. McEachan and colleagues cited a study to underscore this wherein a work place intervention to increase PA in young adults decided not to create matrices of change objectives (step 2 of Intervention Mapping), instead focusing on clear theoretical steps matched with clearly

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57 identified strategies to change PA. This may be a usefu l short cut for researchers developing interventions targeting complex and multi dimensional behaviors such as PA. Additionally, the comprehensive development of IM work is typically carried out without the necessary funding and intervention are not given sufficient consideration prior to implementation, and may help to explain why interventions are often not theoretically rounded or evidence based ( McEachan, et al., 2008 ) Community Based Participatory Research In the past, based on a medical research model, physical activity research has focused on clinically significant results leading to hi ghly controlled, short term interventions with healthy, motivated participants ( Task Force on Community Preventive Services, 2002 ) These types of programs are difficult and costly to maintain and virtually impossible to adopt in real world settings where participants are more likely to have a variety of health issues and be less motivated to engage in physical activity ( Task Force on Community Preventive Services, 2002 ) The role of community based interventions to promote physical activity has emerged as a critical piece of an overall strategy to increase physical activity behaviors among the people of the United States ( Task Force on Community Preventive Services, 2002 ) To date, community based interventions to increase physical a ctivity have not been summarized in an evidence based process ( Goh et al., 2008 ) Community Based Participatory Research (CBPR) has been identified as a key strategy in effectively reducing health disparities in underserved communities ( Pazoki & Nabipour, 2007 ; Wallerstein & Duran, 2006 ) CBPR is defined as a collaborative, partnership approach to research that equitably involves, for example, community members, organizational representatives, and researchers in all aspects of the research process ( Israel, 2001 )

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58 Partners contribute their expertise and share responsibilities and owners hip to increase understanding of a given phenomenon, an incorporate the knowledge gained with action to enhance the health and well being of community members ( Israel, 2001 ) Co mmunity based participatory research (CBPR) has quickly entered the discourse of research methodologies within the past decade, spawning requests for proposals from the Centers for Disease Control, Office of Minority Health, multiple institutes within the National Institutes of Health, and other state or foundation sources that have attracted hundreds of applicants ( Green & Kreuter, 2005 ; Task Force on Community Preventive Servic es, 2002 ) There is considerable evidence suggesting that numerous resources, strengths and skills exist within communities (e.g. supportive interpersonal relationships, community based organizations), that can be engaged in addressing problems and promo ting health and well being ( Goodman, Speers, & McLeroy, 1998 ; Heaney & Is real, 1997 ; Israel & Shchurman, 1990 ; Kretzman & McKnight, 1993 ; Steuart, 1993 ) This understanding of the factors associated with h ealth and disease has contributed to calls for more comprehensive and participatory approaches to public health research and practice ( Israel, 2001 ) CBPR intervention research is based on two primary assumptions for improving health outcomes and reducing disparities: 1) that interventions can be strengthened if they benefit from community insight and incorporate community theories of etiology and change into the empirical scienc e base; and 2) that there is an added value to participation itself for enhancing health ( Wallerstein & Duran, 2006 ) More pointedly, CBPR has been framed a s an orientation to research that focuses on relationships between research partners and goals of societal transformation (Isreal,

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59 2002), rather than a specific set of research methods or techniques. CBPR, however, is not simply a community outreach strate gy but represents a systematic effort to incorporate community participation and decision making, local theories of etiology and change, and community practices into the research effort ( Farag, et al., 2010 ) Numerous advantages of advantages include that it: enhances the relevance an d use of the research data by all partners involved; joins partners with diverse skills, knowledge and expertise in addressing complex problems; improves quality and validity of research buy incorporating the local knowledge of the people involved; provide s resources (e.g. funds, training and possible employment opportunities ) for communities involved can reduce dependency on health professionals, can help ensure cultural and local sensitivity, can facilitate sustainability, enhances productivity and effec tiveness of health programs (Isreal, 2002; Wallerstein & Duran, 2006 ) Actively involving the community in all stages of the research project and providing directly benefit to the community being st udied makes CBPR an attractive research model for health promotion in firefighters. Firefighter communities are distinguished by unique socio culture characteristics that make CBPR an appealing approach to PA intervention efforts. Firefighters work cohesiv ely as a unit in a paramilitary type structure, work together as a unit during in 24 hour shifts, have access to shared resources, are influenced by similar environmental factors, and are governed by the same policies. Recommendations for PA I ntervention R esearch in F irefighters Although many limitations exist in the field of PA health promotion, the information gleamed from these efforts have produced important information for guiding future research and practice. The following section provides a brief ove rview of several

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60 recommendations I am proposing based upon the limitations described earlier in this review that are relevant for promoting PA in firefighter populations. As mentioned earlier in this review, few interventions are grounded in health behavio r theory. Therefore basing interventions on contemporary and relevant health theories of behavioral change or organizational change is critical. When selecting an appropriate theory, it is critical to specify the presumed mechanisms for behavioral change a nd the outcome measures used in evaluating their impact. Incorporating a socio ecological intervention based on changes at the individual, interpersonal, organizational and environmental levels would be a logical conceptual model for PA promotion in firefi ghters given their unique individual traits, social dynamics, shared environmental influences, and paramilitary style of organizational procedures regulating conduct and behavior. Practical strategies may include support for counseling to increase physical activity, promote peer social support, provide skill based education to build self efficacy, increase access to PA at the fire stations by making environmental modifications, and provide opportunities for engaging in physical activity while on duty throug h policy changes. Applying the use of community based approaches to health promotion that address the firefighter worksite culture and encourage fire department management to initiate and support peer group leadership of PA behavior modification may be an excellent approach to use in firefighter populations. Firefighters are known to be a tight nit community who actively participate communal living while on duty, adhere to commonly held traditions of conduct, and are known to spend o ff duty hours with one another. Collaboration of firefighters with researchers in the design, implementation,

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61 than expert only approaches to promoting PA, and may lead to more sustainable healt h program efforts. The use of the principle of variety in physical fitness to foster motivation and emphasize the broad spectrum of physical activity involved in firefighter tasks may also be a critical aspect for PA intervention efforts in firefighters. The recent popularity of functional fitness is relevant for the type of strenuous on duty activities experienced by firefighters. For example, exercise routines could be developed that focus on climbing ladders, dragging heavy equipment (like a body drag), running fire hose lines may be more engaging and practical for developing the fitness related to the type of activities involved in firefighting. As mentioned earlier in this literature review, the use of accurate evaluations for assessing physical fitne ss and intervention effectiveness is a pervasive and historic limitation of PA research. Use validated measures of physical fitness or physical activity, administered under standardized conditions is essential for the evaluation of PA research. For example cardiorespiratory fitness as a critical indicator for aerobic fitness and is related to risk of CVD in firefighters. Use of an accurate assessment for measuring aerobic capacity would then be essential for intervention efforts aimed at improving this com ponent of fitness in firefighters. Sufficient statistical reporting of intervention efforts in addition to validated instruments Is essential (and as mentioned earlier in this literature review often not reported), and include: reporting sample sizes, mean s, standard deviations or frequencies, before and after an intervention for both experimental and control groups.

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62 When regression, covariance, or multivariate analysis is used, report the aforementioned data sufficiently to permit calculation of simple or main effects between intervention and control groups is useful for meta analysis efforts. Limitations from previous research identified in this literature review provide information to guide recommendations for improving the external validity of PA interve ntions. One of the limiting factors for increasing external validity can be the lack of dissemination or adoption of an intervention from one setting to another and appears to be the least reported dimension of external validity of interventions ( Antikainen & Ellis, 2011 ) Future researchers who recruit from community or workplaces should report the number of sites that were screened or invited to participat e in the study ( Antikainen & Ellis, 2011 ) The current trends of basing interventions on theory, writing separate articles on intervention design, efficacy, and process evaluation, and focusing on long term maintenance of behavior change are encouraged by researchers to provide more meaningful information necessary for translational research. To determine if a given intervention is feasible and effective in tr anslational research and not only effective under highly controlled conditions, more information must be reported in future studies about the factors that affect external validity. This detailed reporting for PA intervention efforts in firefighters will be critical for improving the likelihood similar efforts could be adopted or disseminated to other fire departments that are more geographically and ethnically diverse than the one an intervention originated. Strengths and Limitations of Proposed Research Th e following section provides a synopsis of the strengths and limitations of the current research.

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63 Strength A major strength is the uniqueness of the proposed studies as it is among the first efforts to describe the participatory process of community drive n health promotion research in firefighters, to validate the current cardiorespiratory fitness assessment used to measure cardiorespiratory fitness of firefighters, and to pilot test the use of theory driven ecological strategies to reduce CVD risk factors in firefighters. Strength The use of health behavior theory and health planning models is a major strength of this research since studies show interventions using planning models that are grounded in health theory to be more efficacious and effective th an those that are not. Social Cognitive theory and Intervention Mapping were theory and planning model selected for this study respectively. Social Cognitive Theory was mutually selected by firefighters and researchers as a relevant theory to use based on its concept of reciprocal determinism; an individual influences and is influenced by social ( Bandura, 1986 ) This concept resonated with the firefighters who social influences of other firefighters, and the environmental conditions present at the fire station they are assigned to work. Academic partners also found SCT to be particularly useful as they learned more about the unique culture and work structure inherent in the firefighter profession ( McLeroy, et al., 1988 ; T. R. Peterson & Aldana, 1999 ) Unlike some other occupations, firefighters tend to embrace masculine ex pectations for individual behaviors (94% of the profession is male), firefighting requires proficiency and confidence in performing specific skills, firefighting relies heavily upon the social dynamics of team work, firefighters are present in the work env ironments for longer periods of time (24 hour shifts), and are governed by

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64 paramilitary style institutional policies of job performance, conduct, and behavior ( Elliot, et al., 2007 ) Utilizing Intervention Mapping is a major strength since it is designed to systematically apply the use of health theory into the development, implementation, and evaluation of heath promotions. The use of Intervention Mapping is a strength since: it advocates for using logic models to identify d eterminants of health, developing objectives targeting the identified determinants, for creating specific strategies and methods based on health theory, and its use of a comprehensive iterative evaluation processes to provide critical information as to the formative, process, impact, and outcome evaluations of health program and intervention efforts. Strength A strength of this research is the use of a socio ecological approach towards identifying determinants of health outcomes in firefighters and interv ening upon these factors contributing to CVD events in firefighters. Incorporating a socio ecological intervention based on changes at the individual, interpersonal, organizational and environmental levels is a logical conceptual model for PA promotion in firefighters given their unique individual traits, social dynamics, shared environmental influences, and paramilitary style of organizational procedures regulating conduct and behavior. Practical strategies may include support for counseling to increase ph ysical activity, promote peer social support, provide skill based education to build self efficacy, increase access to PA at the fire stations by making environmental modifications, and provide opportunities for engaging in physical activity while on duty through policy changes.

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65 Strength A major strength of this research is the use of Community Based Participatory Research in its approach towards health promotion efforts. The orientation of CBPR has never been studied in promoting health in the fire servic e even though f irefighters are known to be a tight nit community who actively participate communal living while on duty, adhere to commonly held traditions of conduct, and are known to spend off duty hours with one another. Collaboration of firefighters wi th researchers in the design, implementation, and evaluation of PA intervention efforts may produce more more sustainable health program efforts. Strength A major str ength of this research is the use of program evaluations (formative and process), to help create, guide, and if necessary modify, eliminate or incorporate strategies and methods for developing or delivering intervention efforts. Formative and process eval uations can lead to changes that need to take place during the development or implementation of the intervention to improve success. Further, these evaluations can be used to identify the program components that are attributable to the impacts and outcomes of the intervention. These formative and summative evaluation results are critical to addressing threats to the internal and external validity of the entire research project. This detailed reporting of health program evaluation in firefighters will be cri tical for improving the likelihood similar efforts being adopted or disseminated to other fire departments that are more geographically and ethnically diverse than the one an intervention originated. Limitation The nature of Community Based Participatory Research and the process of developing, implementing, and evaluating theory driven health programs

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66 utilizing Intervention Mapping is time consuming and challenging. Examples of these efforts include; identifying and networking with gatekeepers and key info rmants; building partnerships; developing community capacity; leveraging material and human resources; training of community and academic program planners; and development of a comprehensive iterative evaluation plan. Limitation The proposed sample siz e for the treatment group and control groups is small. Twenty four of the least fit firefighters will be recruited into either treatment (n=12), or control group (n=12). A small sample size limits the statistical power to show significance and hinders the generalizability of the results to other firefighter populations. Limitation Another limitation is the availability of fitness equipment and environments to participate in physical activity between fire stations are different. This variability will be mea sured and controlled for in the analysis and taken into consideration in the interpretation of the findings. Additionally, the CVD intervention will tailor efforts to advocate for environmental and policy changes to improve accessibility to fitness equipme nt, as it is a component within the ecological approach of the research design. Limitation Another limitation is that the instrumentation for assessing cardiorespiratory fitness in firefighters has not yet been previously validated. This is a major concer n as cardiorespiratory fitness is strongly associated with CVD in firefighters, and is a main health outcome of the proposed research. To control for this limitation, the submaximal cardiorespiratory fitness VO 2 max protocol used to predict the true VO 2 max of firefighters will be validated. There is no funding for this proposed

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67 research. Without incentives, the firefighters who participate in the study may have distinguishing characteristics from those who choose not to participate. Therefore, participants a nd non participants will be characterized on demographic features, physical activity levels, and reasons why they choose to or not to participate in the study will be ascertained. Limitation Testing changes caused by testing rather than the experiment ma y further threaten the internal validity of the study. For instance, firefighters may improve pre tested fitness levels based on knowing they will be post tested on a specific date. However, this limitation should be present to a similar extent in the comp arison group, thus minimizing the impact on the effect estimate. Limitation. Selection bias may also exist due to potential systematic differences in characteristics of groups selected for treatment and control. Limitation Attrition is a major threat to i nternal validity, especially considering the small sample size. Dropout of participants may occur, especially considering the highest risk firefighters will be recruited into the intervention. Attrition or low rates of participation may not be a random eff ect (may be an underlying reason or distinct characteristic participants are dropping out from the intervention). Issues of missing data may negatively affect statistical analysis and compromise confidence in the results and interpretation of findings. Lim itation Contamination and diffusion of intervention into the control group is a threat to the internal validity of the intervention. The firefighter community is a network of team centered social structures. Firefighters who are in the treatment and contr ol conditions will intermix periodically due to the nature of the profession. Participants in

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68 both treatment and control conditions will be assessed on whether diffusion or contamination of the intervention occurred. Limitation The external validity of t his research is limited. The generalizability of results may be limited to other firefighter populations that are geographically different and/or do not possess the same demographic characteristics represented in the North Central Florida firefighters who participate in this proposed research project. Statement of Purpose The overall objective of the proposed research project is to implement an efficacious peer mentor based worksite health promotion program to significantly improve the risk factors of ca rdiovascular disease (CVD) in firefighters. To achieve this objective, three integrated research studies are proposed in chapters 2 4. The purpose for the first study is to identify the methods for fostering community academic partnerships and utilizing I ntervention Mapping (IM) in a firefighter community. Community Based Participatory Research has never been applied in the fire service for health promotion efforts, yet it may be an effective approach in the shaping and delivery of CVD health promotion pro grams in firefighters. Therefore, the purpose of this study is to describe the methods used to engage firefighters in the participatory processes of planning, implementing, and evaluating a CVD prevention program utilizing IM. The purpose of the second st udy is to validate the cardiorespiratory fitness assessment used to assess aerobic fitness in firefighters. The majority of CVD events occur during prolonged bouts of strenuous exertion that require a high level of cardiorespiratory fitness. Cardiorespirat ory fitness, as measured via expired gases, is significantly related to on du ty CVD events in firefighters. Currently, a submaximal

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69 cardiorespiratory fitness protocol is used to estimate the maximal aerobic capacity (VO 2 max) of firefighters; however, it ha s not yet been validated. Firefighters identified the need to validate the instrumentation used to assess cardiorespiratory fitness of firefighters as a high priority. Therefore, the purpose of the study is to evaluate the validity of the submaximal VO 2 max protocol used to predict the true VO 2 max of firefighters. The purpose of the third study is to evaluate the efficacy of a pilot cardiovascular disease prevention program in firefighters. The purpose of this is to examine the use of a peer driven firefig hter worksite health promotion intervention on increasing physical activity, improving cardiorespiratory fitness, body composition, and other physical for Significance Epidemiological studies show a high prevalence of risk factors for CVD among firefighters exists, including: inadequate physical fitness, high rates of obesity, hypertension, and unhealthy cholesterol profiles ( Haas, et al., 2003 ; Kales, et al., 2003 ; Leiba, et al., 2011 ; Rosenstock & Olsen, 2007 ; Soteriades, et al., 2008 ) Even new firefighter recruits are commonly found to be overweight and have low cardiorespiratory fitness ( S. N. Kales, et al., 2007 ; Poston, et al., 2011 ) Despite the high rates of CVD among firefighters, more than 70% of fire departments lack programs to promote physical fitness and health, do not require firefighters to exercise regularly, or do not require firefighters to undergo periodic medical examinations to screen for CVD risk factors ( Geibe, et al., 2008 ) The substantial health and fitness issues facing the fire service have, in large part, not been a dequately addressed from the public health research community ( Poston, et al., 2011 ) Few studies have evaluated interventions for

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70 addressing physical fitness, weight gain, high blood pressure, or unhealthy cholesterol in the fire service culture. The significance of this research is that these studies are among the first efforts to describe the participatory process of community driven health promotion research in firefighters, validate the current cardiorespiratory fitness assessment use d to assess aerobic capacity of firefighters, and use theory driven ecological strategies to intervene on risk of CVD in firefighters. Research Aims This study was designed to understand the methodology of health promotion efforts to increase physical act ivity and reduce risk of CVD in firefighters, to investigate the validity of the current aerobic capacity assessment used in firefighters to predict their true aerobic capacity, and to evaluate the effectiveness of health intervention on CVD in high risk f irefighters. Therefore, the specific aims of this research this as follows: Aim 1 To describe how the principles of Community Based Participatory Research were integrated and operationalized into each of the six steps within Intervention Mapping. Aim 2 T o evaluate the validity of the firefighter Wellness Fitness Initiative sub maximal VO 2 test to predict the true VO 2 max of firefighters. Aim 3 To evaluate the use of a peer driven firefighter worksite health promotion intervention on increasing physical ac tivity, increasing VO 2 max decreasing body fat percentage, and increasing musculoskeletal physical fitness indicators in unhealthy firefighters. Chapters 2 4 describe three inter related manuscripts based on these aims and strategies. The first manuscript describes the methods used to engage firefighters in the

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71 participatory processes of Community Based Participatory Research and Intervention Mapping (IM). This manuscript describes methodologies used in planning, implementing, and evaluating of a CVD inter vention. The second manuscript evaluates the validity of a Cardiorespiratory Fitness ( VO 2 max ), assessment used to measure the aerobic fitness of firefighters. The final manuscript will describe the implementation and evaluation a pilot CVD prevention progr am for firefighters. Finally, Chapter 5 of this dissertation proposal will present a synthesized conclusion of the strengths and limitations of the proposed studies.

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72 CHAPTER 2 METHODS FOR FOSTERIN G COMMUNITY ACADEMIC PARTNERSHIPS AND UTILIZING INTERVENT ION MAPPUNG IN A FIR EFIGHTER COMMUNITY Background Firefighting is a dangerous profession as it has one of the highest occupational fatality and injuries rates in the United States annually ( Kales, et al., 2007 ; National Institute for Occupational Safety and Health, 2001 ; United States Fire Service & National Fire Data Center, 2002 ) What is less commonly known is cardiovascular disease (CVD), rather than burns or smoke inhalation, constitutes the most frequent cause of death and disability in firefig hters ( Duenas Laita, et al., 2007 ; Geibe, et al., 2008 ; Rosenstock & Olsen, 2007 ) CVD accounts for 46% of all on duty fatalities in firefighters, compared to 22% of fatalities in police, 10% in emergency medical service workers, and 11% of all deaths in the general work force ( Kales, et al., 2007 ; Soteriade s, et al., 2008 ) The disproportionate rates of CVD in the firefighting profession have emerged as a major public health concern in recent years. Over the past decade epidemiological studies have worked to identify the on duty tasks and biological based risk factors most commonly related to CVD in firefighters. Studies show the majority of CVD events occur during activities requiring strenuous physical exertion; suppressing a fire (36%), performing physically demanding medical emergency duties (15%), res ponding to an alarm (13%), and engaging in physical training (12%) ( Geibe, et al., 2008 ; Murphy, et al., 2002 ) These types of on duty activities requir e firefighters to work at near maximal heart rates for prolonged periods of time, under the stress of high temperatures, while using heavy equipment ( Geibe, et al., 2 008 ; Holmer & Gavhed, 2007 ; Rossi, 2003 ) Therefore, the relationship between physical fitness and CVD during the performance of firefighting duties has received

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73 considerable attention among concerned firefighters, public health officials, and researchers ( Leiba, et al., 2011 ; National Institute for Occupational Safety and Health, 2001 ; Poston, et al., 2011 ; United States Fire Service & National Fire Data Center, 2002 ) Biological risk factors related to CVD events in firefighters include poor cardiorespiratory endurance (also referred to as VO2maxor aerobic capacity), having high percentage of tot al body fat, an overweight or obese Body Mass Index classification (BMI), hypertension, dyslipidemia, and poor musculoskeletal fitness profiles ( Harvey, et al., 2008 ; Leiba, et al., 2011 ; Rhea, et al., 2004 ; Soteriades, et al., 2008 ; Yoo & Franke, 2009 ) Rates of low VO 2 max are shown to be highly prevalent among the firefighter population as studies find 25% of firefighters fail to achieve a the current minimum standard for VO2max of 42.0 ml/kg/min in firefighters ( Harvey, et al., 2008 ; Mier & Gibson, 2004 ; Poston, et al., 201 1 ) Research finds 90% of all CVD fatalities occurred in firefighters who were classified as being either overweight or obese T his is concerning since several studies show 53% of all firefighters are overweight, 35% are obese, 2.5% are extremely obese, and only 12% of firefighters have a healthy body fat percentage or BMI ( Clark, et al., 2002 ; Fahs, et al., 2009 ; Yoo & Franke, 2009 ) A high prevalence of having one or more of these biologicall y based CVD risk factors exists in firefighter populations ( Donovan, et al., 2009 ; Leiba, et al., 2011 ; Poston, et al., 2011 ) Even new firefighter recruits are commonly found to be overweight and have low to normal aerobic capacities and lack the minimum exercise tolerance thought necessary to safely perform physi cally demanding on duty tasks ( Clark, et al., 2002 ; Leiba, et al., 2011 ; Poston, et al., 2011 )

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74 A large body of evidence shows regular aerobic Physical Activity (PA) is a protective factor against developing CVD as it increases VO 2 max, is a critical component in weight management and reducing body fat, and is shown t o both prevent and manage hypertension and cholesterol levels ( Braith & Stewart, 2006 ; Fitzgerald, et al., 2 004 ; Haskell, et al., 2007 ; Kesanniemi, et al., 2001 ; Nocon, et al., 2008 ; Sofi, et al., 2008 ) Regular PA is also necessary to develop the physical fitness required to safely meet the strenuous demands on duty tasks most commonly linked to CVD events in firefighters ( Fahy, 2005 ; Holmer & Gavhed, 2007 ; Rossi, 2003 ) Therefore, researchers, public health officia ls, and concerned firefighters recommend programs promoting regular PA, physical fitness evaluations, and annual CVD screenings as part as part of a comprehensive effort to reduce CVD risk in firefighters ( Kales, et al., 2007 ; Leiba, et al., 2011 ; National Institute for Oc cupational Safety and Health, 2001 ; Poston, et al., 2011 ; United States Fire Service & National Fire Data Center, 2002 ) Despite t he protective factors PA offers, most fire departments do not require firefighters to exercise regularly ( Kales, et al., 2007 ; Kales, et al., 2003 ) According to the 2008 International Association of Firefighte rs report more than 70% of fire departments lack programs promoting PA or cardiovascular health, do not require firefighters to exercise on duty, do not require incumbent firefighters to maintain physical fitness standards, and do not require medical exami nations to screen CVD risk factors ( Geibe, et al., 2008 ) Additionally, little evidence based research exists regarding the use of PA health promotion programs as a means to reduce CVD risk factors in firefighters (MacKinnon 2010, ( Elliot, et al., 2007 ; Kales, et al., 2003 ; Poston, et al., 2011 ) The lack of programs and studies promoting PA in firefighters underscores the

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75 need for researchers and firefighter communities to collaborate on best practice and evidence based efforts to reduce CVD in firefighters. Decades of research examining the determinants of PA behaviors and the effectiveness of interventions to promote PA provides meaningful insight towards identifying the appropriate theoretical understandings and health planning models to use for increasing physical fitness via PA firefighters ( Biddle & Nigg, 2000 ; Farag, et al., 2010 ; Greaves, et al., 2011 ; Kahn, et al., 2002 ; Sallis, et al., 2000 ) Theory based health promotion efforts are more likely to succeed when delivered through a well designed health planning model ( Green & Kreuter, 2005 ) Intervention Mapping (IM) is a protocol specifically designed for systematically applyi ng theoretical strategies when designing, implementing, and evaluating health promotion programs ( Bartholomew, et al., 2006 ; Kok, et al., 2004 ) Incorp orating principles of Community Based Participatory Research (CBPR) may be an efficacious orientation for guiding firefighter community involvement in the application of IM in the development, delivery, and evaluation of health programming since studies sh ow worksite health promotion efforts involving the target community in the research process has been successful for increasing physical activity ( Israel, et al., 2005 ; Pazoki & Nabipour, 2007 ) The purpose of this study is to describe how C BPR was integrated into t he steps of IM to engage firefighters in the participatory process of screeni ng for CVD risk factors, developing and delivering a CVD intervention for high risk firefighters, and in validating instrumentation used to assess cardiorespiratory health in firefighters. This study describes the participatory processes between firefighte r and academic partners in health program planning, implementation, and evaluation processes. This study is

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76 among the first efforts to describe the participatory process of community driven health promotion research in firefighters. The information present ed in this manuscript includes a brief background on how a Community Academic Partnership ( CAP ) was formed, a brief background on CBPR and IM, the results section describing how CBPR principles led to participatory outcomes within each step of IM, and a di scussion section on the strengths and limitations of integrating IM and CBPR in health promotion efforts to reduce CVD in firefighters. Methods Formation and Structure of the Community Academic Partnership A CAP between firefighters and researchers was formed buy integrating the orientation of CBPR principles with IM methods to develop and disseminate a worksite health promotion program targeting CVD risk factors in firefighte rs. The CAP was comprised of two fire departments, a local public health depart ment, and three health oriented university academic departments. This collaboration was initiated when local firefighters recognized a need for better physical fitness in their department and approached the researchers of this study for assistance in devel oping and delivering an effective health program for promoting physical activity. Soon after, the firefighters and academic partners jointly created their CAP and developed contractual agreements regarding equal involvement and guidelines for communication between all partners at the onset of this collaboration. The formal creation of the CAP itself resulted from stakeholder meetings between fire chiefs, firefighters, and the principal investigators of the study. These formative meetings were conducted over a span of six months and were integral in creating the infrastructure for the CAP and in facilitating partnerships from the needs assessment and throughout each step of the IM planning process.

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77 Selection of CBPR & IM P rocess CBPR is recognized as a critic al orientation in efforts to effectively reduce health disparities in underserved communities ( Pazoki & Nabipour, 2007 ) collaborative partnership approach to research that equitably involves community members, organizational representatives, and rese archers in all aspects of the research ( Wallerstein & Duran, 2006 ) Community members and partners contribute their expertise and share responsibil ities and ownership to increase understanding of a given phenomenon, and to incorporate the knowledge gained with action to enhance the health and well being of community members ( Wallerstein & Duran, 2006 ) The orientation of CBPR is based on nine interrelated principles and are described in Table 2 1 and include recognizing the community as a unique unit, involving the community in all phases of the researc h process, promoting co learning, building on the strengths of the community, emphasizing local relevance and an ecological approach to health, iterative system development, and long term commitment to sustainability, the balance between research and actio n via information and learning are shared equally by all members, and disseminates findings and knowledge gained to all partners. CBPR was selected as an approach towards health promotion efforts in firefighters since they expressed interest in being invol ved in all aspects of the research processes as they CBPR was seen as a logical fit for based on the social dynamics characterizing the firefighter community includ ing the high emphasis on team work, communal style living routines, being present in the work environment with one another for 24 hour shifts, and the use of paramilitary style policies governing job performance, conduct, and behavior.

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78 IM is a health prom otion planning model that describes the process of program development, implementation, and evaluation in six iterative steps and is described in Table 2 2: (1) needs assessment (2) creating matrices of program objectives based upon scientific analyses of health determinants; (3) the selection of theory based intervention methods and practical strategies to change determinants of health related behavior; (4) developing program design, components, and materials; (5) the program adoption, implementation and s ustainability; and (6) the evaluation process. IM is presented as a series of steps, however, the planning process is cyclical (iterative), rather than linear ( Bartholomew, et al., 2006 ) For example, planning for step 6 (evaluation), is typic ally the first step to be undertaken when using IM. The use of IM was selected because researchers advocated for the use of health behavior theories since health promotion programs are more likely to succeed when grounded in theory, and IM is a planning mo del that is specifically designed for surfacing and applying relevant theories in health promotion. Additionally, the comprehensive iterative evaluation of IM provides critical information as to the formative, process, impact, and outcome evaluations inter vention efforts, and allows changes to take place during the development or implementation of the intervention to improve the success of health promotion efforts. Both CBPR and IM are founded upon the ecological model, wherein as it has evolved in the beha vioral sciences and in public health, the ecological model focuses on influential factors at the individual, interpersonal, community, environmental, and policy levels of health. Incorporating CBPR and IM in promoting health of firefighters may be an effec tive strategy due to the unique characteristics inherent in the firefighter

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79 profession. Compared to most other professions, firefighter have distinct personality traits, rely more heavily upon the social dynamics of team work, have unique cultural norms, a re present in the work environments for longer periods of time (24 hour shifts), and are governed by paramilitary style institutional policies of job performance, conduct, and behavior ( Elliot, et al., 2007 ) Therefore, the o rientation of CBPR and Intervention Mapping may have practical applications for guiding health promotion efforts to reduce CVD in firefighters. Results The following sections describe results in the context of how the CBPR principles and the participatory outcomes of the CVD program were operationalized within each of the 6 steps in the IM process. Table 2 3 identifies the specific CBPR principles that were integrated into each step of the IM steps. Six principles of CBPR were primarily and consistently us ed throughout the IM steps process. The most frequently utilized principles of CBPR was the promotion of co learning and capacity building as it was integrated into 5 IM steps (integr ated into IM Steps 1 4 and 6). Three CBPR principles were integrated into 4 steps of IM and included facilitating partnerships in all phases of the research process ( S teps 1, 2, 5, and 6), building upon the strengths of the community (Steps 1 and 3 5), and involving system development through iterative process (Steps 1, 2, 4, 6 ). Emphasizing local relevance and an ecological approach to the determinants of health was incorporated into 3 IM steps (Steps 2 4). Involving a long term commitment was primarily emphasized in one step of IM (Step 5: Program Adoption, Implementation, an d Sustainability). The CBPR principle of recognizing the community as a unit is an inherent fixture of the efforts undertaken by the CAP and was implied throughout the whole process of health promotion efforts. The balance between

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80 research and action was s een mostly in the engagement phase of the CAP, however, is not explained in this study. The dissemination of findings is not relevant since the results of this study are now just emerging and will be ready to disseminate in the near future. IM Step 1 Ne eds Assessment The needs assessment step of IM int egrated the CBPR principles of i nvolving system development through cyclical and iterative processes, facilitating partnerships in all phases of the research, promoting co learning and capacity building, a nd buildi ng on Involving system development through cyclical and iterative process was demonstrated by operationalizing Steps 2 and 6 of IM (Developing Matrices of Change and Evaluations respectively), in conjunction with the needs assessment. The steps of conducting the needs assessment, developing matrices of change, and evaluations occurred simultaneously since each of these steps in IM are Planning for the needs assessmen t was integral in facilitating partnerships The needs assessment was developed through strategic planning meetings and was conducted in several phases: understanding the health concerns of CVD in local firefighters, identifying risk and protective factors related to CVD in firefighters, selecting and validating instruments used to measure risk factors for CVD, and conducting screenings to assess CVD risk factors for al l firefighters in the department. Co learning occurred during the initial strategic planning meetings since the focus of them was in understanding the health needs of firefighters. These meetings resulted in identifying the promotion of PA to reduce risk of CVD as a primary health concern for

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81 firefighters. Next, the CAP meetings focused on understanding the relationship between PA behaviors and CVD in firefighters. Academic partners provided expert advice and results of systematic literature reviews on the topic of PA behavior and CVD to firefighter stakeholders including: how CVD is the leading cause of death and disability in firefighters, the majority of CVD occurs while performing strenuous activity, CVD risk factors are highly prevalent in the firefigh ter population and include poor physical fitness, hypertension, obesity, and dyslipidemia. The firefighters then provided feedback on the relevancy of how this evidence based information could be applied towards conducting a needs assessment and developing a health promotion program in their department. Firefighters explained to academics screening for CVD in firefighters is rare and little efforts are undertaken to promote PA in firefighters. The firefighters expressed the desire to conduct CVD screening t hroughout the entire department as part of the needs assessment. CAP meetings then focused upon building capacity via selecting specific measurements for assessing CVD risk factors in firefighters. The CAP agreed to build upon the strengths of the firefigh ter community by utilizing the firefighter Wellness Fitness Initiative (WFI), for determining the protocols used in the physical fitness and CVD needs assessment. The WFI was developed by the Fire Service Joint Labor Management Task Force, and is specifica lly tailored for assessing the physical health of the firefighter population. The CVD risk factors and physical fitness assessments selected for the needs assessment included: a sub maximal cardiorespiratory fitness treadmill test (measures aerobic capacit y or VO 2 max), blood pressure, Body Mass Index, total percent body fat (via skin fold analysis), arm strength, leg strength, hand

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82 grip stre ngth, and abdominal endurance. Additional measures for the needs assessment included self reported frequency, intensit y, and duration of physical activity. The firefighters and academics partners worked together to pool the material resources and equipment needed for con ducting the needs assessments. The CAP built upon the strengths of the firefighter community by designa ting them with the responsibility of administering the CVD screenings as it capitalizes on their expertise in administering medical based procedures (i.e. measuring blood pressure or heart rate). Firefighter partners identified, recruited, and trained 8 fi refighters to administer the WFI assessments. The CAP agreed criteria for selecting these firefighters should be based on those who were seen as positive role models among their peers, who were pro health conscious, and for those who could commit to admini stering screenings in the foreseeable future to ensure consistency in data collection. The selected firefighters received training from both stakeholder firefighters and academic partners on how to administer each of the assessments to also ens ure consiste ncy and accuracy. The firefighters then conducted WFI assessments on all 144 firefighters in their department over a 3 week period. A 100% rate of participation was achieved because of the cooperation with the fire department administration in requiring m andatory screening for all firefighters, and because they were conducted during on duty shifts. On average, the time required to run one firefighter completely through the battery of assessments was 30 minutes. Typically 3 4 trained data collectors would r un a crew of 3 4 firefighters through the assessment simultaneously, thus reducing the amount of time each fire crew was out of service to run emergency calls.

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83 After the screenings, the CAP determined that in addition to a department wide effort to promot e PA, a research based intervention specifically tailored towards high risk firefighters was critical. The CAP also identified the need to validate the protocol used to measure cardiorespiratory fitness of firefighters in the needs assessment. The validity of this test was called into question since it is a sub maximal treadmill test used to predict their true maximal cardiorespiratory fitness (VO 2 max). The firefighters believed the sub maximal test may not be accurate based on antidotal evidence and observ ation, and academic partners suggested validating it with laboratory based standardized protocols for measuring true VO 2 max. Subsequently, strategic planning meetings were conducted to develop research priorities (community wide PA health promotion program research based pilot intervention for high risk firefighters, and validation of the sub maximal VO 2 max test), according to the methods involved in creating matrices of change in Step 2 of IM. IM Step 2 Developing Matrices of Change Objectives The second all phases of the research process, promoting co learning and capacity building, iterative process to system development, and emphasizing local relevance and an ecological perspective of performance and change objectives was integral in facilitating collaboration between firefighters and academic partners. Additionally, the process of creating objectives based on the ecolog ical perspective of health relevant to needs of local firefighters fostered co learning for all those involved in developing the matrices. Co learning and information gleamed from the use of the ecological perspective helped to identify

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84 relevant health the ories to use in program planning, and led to the iterative processes of system development since theory selection is Step 3 in IM. This IM step provided the foundation for developing a department wide PA health program, a pilot test intervention for high risk fire firefighters, and led to planning for validating the WFI sub maximal VO 2 max test. The process for creating the matrices involved identifying determinants of PA behavior in firefighters from an ecological perspective (gathered from the literature review and feedback from the firefighters during the needs assessment), followed by specifying change and performance objectives to address these determinants at the individual, interpersonal, environmental, and policy levels. Co learning occurred as acade mics studied the individual characteristics, social dynamics, cultural norms, work structure, environmental factors, and who the agents of change were within the fire department. Information gained from this co learning helped to identify relevant health b ehavior theories to use in the creation of change objectives. Social Cognitive Theory (SCT) was selected among the theories deliberated by the CAP and is discussed further in the next section (Step 3 in IM). Matrices of performance and change objectives w ere created to both address determinants of PA in firefighters and for the logistics required to build capacity for the department wide health program and intervention for high risk firefighters. Firefighters learned to create specific, time oriented, and measurable performance and change objectives based off of individual, interpersonal, environmental, and policy factors of PA related to SCT Performance objectives regarding logistics for developing capacity to implement the community wide and pilot interv ention were developed on how to identify, recruit, and train firefighters to serve as peer mentors. Objectives based on criteria for

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85 selection peer mentors included recruiting: firefighters who possessed a strong working knowledge and commitment to physica l fitness, those who were well respected among their peers, and those who have a sincere desire to enhance the physical fitness of their co workers. Objectives were then developed regarding methods and strategies for training peer mentors and included crea ting a 40 hour training program based on the behavior theory based curriculum developed by the investigators of this study. The American Council on Exercise training progra m focused on teaching education based information regarding the components and principles of physical fitness. Performance objectives were created to provide training for peer mentors on how to apply behavioral change strategies to firefighters that were c onsistent with SCT and included: the modeling of health behaviors (observational learning), goal setting (expectancies), skill building techniques (behavioral capability), motivational reinforcement strategies, and methods for building confidence (self ef ficacy). Change objectives were created to focus on addressing the pros and cons of firefighters held regarding participating in PA (expectancies), developing PA regiments based on preference for PA, current fitness level of participation in PA (behavioral capability), and for building self efficacy via overcoming common barriers towards participation in PA (such as time management). Change objectives regarding the training of peer mentors also included strategies based on the community, environmental, and policy levels within the ecological model to create positive social normative attitudes towards aerobic fitness, ideas for modifying environmental factors to encourage PA, and methods to advocate for policies in promoting on duty PA in the fire department Capacity building objectives focused on

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86 environmental modifications at each fire station for promoting health enhancing be haviors to reduce risk of CVD. Change objectives were created to identify fitness equipment needs at each of s gyms. Performance objectives were created to obtain internal city funding to purchase new fitness equipment, and to also allow firefighters to build equipment their own fitness equipment based on the needs at each fire station (such as pull up bars and f unctional training equipment). These objectives were aimed at maximizing environmental changes with limited financial resources. Matrices of performance and change objectives for policies governing firefighter behavior in the work environment were based o n evidence they have a significant impact on health behaviors in firefighters ( Kales, et al., 2007 ; Leiba, et al., 2 011 ; National Institute for Occupational Safety and Health, 2001 ; Poston, et al., 2011 ; United States Fire Service & National Fire Data Center, 2002 ) The paramilitary style of policies regarding job performance, conduct, individual behavior, and team work predisposes the firefighter pr ofession as a fully capable organization to institutionalize health related policies. Policy based change objectives included institutionalizing annual fitness and CVD screenings, creating minimum performance standards for the screenings, requiring on duty physical activity (workout time), and providing quarterly health education classes delivered at the worksite (physical fitness and nutrition skill and knowledge building experiences). Policy objectives included encouraging firefighters to advocate for the aforementioned policies to increase PA within the department and targeted agents of change including the fire chief, station chiefs, and the firefighter union representatives.

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87 Additional details regarding the specific strategies and methods created from t he performance and change objectives for the design and implementation of the community wide health program and high risk pilot intervention are explained in greater detail in Steps 4 and 5 of IM (Program Development and Program Adoption, implementation, a nd Sustainability respectively). Matrices of objectives were created to validate the WFI sub maximal VO 2 max assessment used to predict the true VO 2 max of firefighters. Matrices of performance objectives were created wherein firefighters took the lead role in identifying and recruiting firefighters to participate (serve as subjects), in the validation of the VO 2 max assessment. Firefighters who volunteered for the validation study had to complete both the WFI sub maximal VO 2 and Bruce VO 2 max protocol (laborat ory based protocol), on two separate occasions w ithin one week of one another. Performance objectives were created wherein academic partners took the lead role in administering and collecting data of the WFI sub maximal and Bruce VO 2 max protocol, as well a s the lead in managing and analyzing the data. IM Step 3 Selecting Theory Informed Intervention Methods and Practical Strategies The IM step of selecting theory informed methods and strategies integrated the learning and c apacity building, building upon strengths of the community, and emphasizing local relevance and the ecological the selection of theory since this step of IM was initiated during the matrices of change when ecological determinants were being investigated in order to inform the development of change and performance objectives. Building on the strengths of the

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88 community is demonstrated through utilizing peer mentors based on t he applications of SCT for program development and implementation. As part of the co learning process academics explained to firefighters a health promotion program is more likely to benefit participants and communities when it is guided by health behavi or theory ( Green & Kreuter, 2005 ) Academics provided ba ckground on how theory is specifically tailored to the target population and how it is translated into meaningful and practical strategies ( Bartholomew, et al., 2006 ) Researchers shared several relevant health behavior theories with firefight er partners to select from based on the ecological determinants identified in Steps 1 and 2 of IM that could serve as the underpinnings for designing specific methods and strategies for the department wide health program and pilot intervention for high ris k firefighters. The health behavior change theories shared with firefighters included the Health Belief Model, Theory of Planned Behavior, TTM and SCT After careful review of these theories, a consensus was reached that SCT held the most promise for prom oting PA to reduce CVD risk factors in firefighters. The decision by the CAP to use SCT was largely based the concept of reciprocal determinism ( Bandura, 1986 ) This concept resonated with the firefighters who asserted the interaction of a firefig of other firefighters the individual traits that are commonly found to characterize firefighter personalities, and the environmental conditions present at the fire station they are assigned to work. Academic partners also found SCT to be particularly useful as they learned more about the unique culture and work structure inherent in the firefighter

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89 profession ( McLeroy, et al., 1988 ; T. R. Peterson & Aldana, 1999 ) Unlike some other occupations, firefighters tend to embrace masculine expectations for individual behaviors (94% of the profes sion is male), firefighting requires proficiency and confidence in performing specific skills, firefighting relies heavily upon the social dynamics of team work, firefighters are present in the work environments for longer periods of time (24 hour shifts), and are governed by paramilitary style institutional policies of job performance, conduct, and behavior ( Elliot, et al., 2007 ) Firefighters and academics also found SCT to be the most appli cable theory for translating conc epts into practical strategies because of its use of increasing confidence to be physically active ( self efficacy ), through role modeling of behaviors (observational or vicarious learning), by addressing firefighter beliefs regarding outcomes for participa ting in PA (outcome expectations and outcome expectancies), use of skill building experiences (behavioral capability), and for its focus on addressing environmental factors for promoting PA. Subsequently, the CAP worked to build confidence in firefighters to be physically active via using peer mentors, addressing firefighter expectations about PA, participating in skill building PA related to firefighter tasks, and by modifying fire stations to make PA more accessible. Academics learned firefighters expect ed PA would result in improved health and job performance (outcome expectations), and placed a high value on achieving a healthy physical fitness (Outcome expectancies). However, most firefighters placed a higher value on muscular strength (the ability to exert a maximal amount of force through one repetition of movement) than cardiorespiratory fitness (the ability of the heart and lungs to work efficiently for prolonged periods of time) because they thought

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90 muscular strength was more important for performi ng firefighting skills effectively. Academic partners worked to change these expectations by providing overwhelming evidence cardiorespiratory fitness is a critical component of fitness since most CVD events occur when performing tasks for prolonged perio ds of time ( Geibe, et al., 2008 ; Holmer & Gavhed, 2007 ; Rossi, 2 003 ) Academics also learned firefighters believed possessing muscular strength was seen as being more masculine then being aerobically fit, as this type of fitness was seen as being more feminine in nature. Subsequently the CAP created strategies to ch ange these social normative attitudes held by firefighters via using role model firefighters, famous athletes, and celebrities who possessed high levels of aerobic fitness and who were also seen as being masculine. The concept of observational learning in SCT contends a person learns a behavior by observing other individuals receiving the negative or positive consequences of performing a behavior ( Bandura, 1986 ). The CAP operationalized this construct via utilizing influential firefighters to serve as a Peer Fitness Trainers (PFT), for role workers, and to help lead intervention efforts aimed at high risk firefighters. The PFT worked to increase the beh avioral capability of firefighters to improve cardiorespiratory fitness through leading skill building experiences focused on sustaining efficient loco motor movements on a wide variety of activities involved in firefighter tasks. The PFT demonstrated and led activities involving self paced learning of basic movements that became progressively more complex to perform. Firefighters were taught a wide variety of activities by PFT that constantly changed over time as to maintain interest and motivation to perf orm PA.

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91 The environmental factors affecting behavior as postulated by the concept of reciprocal determinism within SCT was addressed by taking an inventory of each fire station within the department (8 fire stations). Fire station environments varied in t erms of accessibility to participate in PA and PFTs took charge of identifying fitness modify the work environment to increase PA. The specific changes to fire station en vironment are explained in further detail in s tep s 4 and 5 of IM (Program and Adoption, Implementation, and Sustainability respectively). The modifications to the work environment was designed to be the culmination of the efforts to increase the self effic acy of firefighters to engage in aerobic fitness through addressing their expectations and expectancies of PA, using vicarious reinforcements of role model peer mentor firefighters, and buy increasing their behavioral capability via skill building experien ces to engage in aerobic activity. IM Step 4 Producing Program Components and Materials through iterative and cyclical process, builds on strengths and resources of the commun ity, emphasizes local relevance and ecological perspective on multiple determinants of health outcomes, and promotes co based CVD dep artment wide health program and pilot intervention for high risk firefighters. This following section describes how building upon the strengths of the strategies and methods utilized within the multi component health programs.

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92 Ten fire fighters meeting criteria for becoming a peer mentor created in Step 2 of IM (firefighters who possessed a strong working knowledge and commitment to physical fitness, were well respected among their peers, and ha ve a sincere desire to enhance the physical fitness of their co workers), were identified and recruited, with a total of 8 firefighters agreeing to participate in the training, development, and implementation of the health program. Once formally recruited, the 8 firefighters received 40 hours of program, and from curriculum developed by the academic partners. The PFTs received additional training provided by the academic partner s on behavioral change strategies including motivational interviewing, modeling of health behaviors, goal setting, skill building techniques, reinforcement techniques (i.e. verbal cues, incentives), and methods for building confidence. Training from academ ics also included strategies PFTs could use to create positive social normative attitudes towards aerobic fitness, ideas for modifying environmental factors, and methods to advocate for policies promoting PA. Once certified through this training, the CBPR principle of system development through iterative and cyclical process was operationalized as the PFTs were invited by the CAP to participate in the development of a second wave of performance objectives for matrices of change (step 2 of IM). The PFTs wer e encouraged to build upon the strengths and resources of their community through using the knowledge and skills they received from their training to develop, implement, and objectively evaluate a firefighter driven PA program to reduce CVD in both high ri sk firefighters and in the entire fire department. The PFTs worked to select protocols and establish standards for the

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93 annual department wide CVD screenings, developed criteria for identifying firefighters at highest risk of CVD, created experimental metho ds for pilot testing a one on one peer driven CVD intervention tailored for high risk firefighters, strategies for implementing policy changes to increase physical activity to improve fitness, and improving environmental access to PA equipment. Department w ide PA p rogram One PFT was assigned to each of the 8 fire stations. The department wide program focused on the effects of team centered approaches for promoting PA, addressing social norms towards participating in aerobic PA, making environmental modific ation to increase opportunities for PA, and advocacy approaches implementing policies regarding PA. Each of the PFTs provided quarterly health education classes delivered at their assigned station (physical fitness and nutrition skill building experiences) In addition, the PFTs encouraged firefighters at each of their stations to engage in weekly team centered workout challenges and monthly department wide fitness competitions. The team ated by each station and was posted in each of the gym areas at t he respective fire stations. Each fire station was encouraged to engage in their workouts in a manner of friendly competition between themselves and the other fire stations. Peer Fitness Tra iners worked to build upon the strengths of the firefighter gyms based on their observations and from feedback of firefighters assigned to these stations. The PFTs determi ned each of the fire stations should receive a variety of aerobic functional training exercises equipment. Aerobic functional training equipment is relatively inexpensive, has been shown to improve aerobic capacity ( Barwick et al.,

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94 2011 ) and is specific to firefighter job duties that require physical exertion. Instructions for using the aerobic functional training equipment and environmental modifications were provided by the PFTs in the quarterly he alth education sessions. The equipment was acquired through a combination of financial support from the department chief (who allocated a fixed budget for equipment purchases), and was built by the trainers themselves or obta ined through low cost methods. For example, pull up bars were built outside of each station by PFTs and large tires for functional training were collected from junkyards for free. The PFTs worked to build community capacity via encouraging firefighters and upper level management to sup port policy change aimed at institutionalizing annual CVD screenings, creating minimum standards for CVD risk factors and physical fitness, requiring on duty physical activity (workout time), and for providing the quarterly health education classes deliver ed by the PFTs at their assigned fire stations. The PFTs collaborated with the union leadership and fire department leadership to come to a consensus on creating policy change targeting firefighter health and fitness. For example, they came to the consensu s that a policy supporting annual fitness and health screenings and compliance with the program would be acceptable to the union as long as it was non punitive in nature. Another policy change made at the organizational level is the implementation of manda tory on duty physical fitness training. Policy was established requiring firefighters to participate in one hour of physical activity of their choice each shift, with an emphasi s on aerobic fitness training. Working together with relevant stakeholders, th e PFTs were able to develop and implement various policy

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95 changes within the fire department that protected the interests of the union and department leadership while promoting the overall health and fitness of the firefighters. In addition to policy and e nvironmental changes, the PFTs targeted extrinsic motivation at the individual level. They obtained agreement from the department leadership to allocate a fixed amount of money to be spent on incentives to for firefighters who maintain a healthy range of p hysiological results for aerobic fitness, blood pressure, lipid profiles, and body composition at annual testing. Additionally, firefighters who do not fall within ideal standards for CVD measures, but have shown improvement from previous assessments wer e also awarded the incentives. For example, stainless steel water bottles, and workout clothes with firefighter logos were given out as incentives in the first year of the program. Pilot i ntervention for h igh risk firefighters The aim of the pilot study was to assess the effects of one on one counseling with PFTs has on CVD and physical fitness indicators in high risk firefighters. Every firefighter from the fire department (n=144), completed the needs assessment to identify firefighters who met the criteria for classifying firefighters as high risk for CVD. The criteria for identifying high risk firefighters was based on possessing both a VO 2 max score below 40 mlO 2 /kg/min (recommended VO 2 max of 42mlO 2 /kg/min is recommended to safely perform fire fighter duti es), and possessing a percentage of body fat >25% (considered to be obese). TheVO 2 max values and body fat percentages were used as the discriminating risk factors because they are highly associated to CVD events in firefighters ( Kales, et al., 2007 ; Leiba, et al., 2011 ; N ational Institute for Occupational Safety and Health, 2001 ; Poston, et al., 2011 ; United States Fire Service & National Fire Data Ce nter, 2002 ) Firefighters identified as high risk (n=24), were then

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96 recruited into the study and randomly assigned into either treatment or control groups. The treatment group was exposed to a one year peer mentor intervention delivered by firefighters a nd based on SCT and the ecological model. Both intervention and control groups completed three month and one year follow up post testing from the baseline measures taken during the needs assessment. The pilot intervention consisted of one on one meeting be tween the high risk firefighters and PFT was based on custom tailoring exercise plans individualized to fitness levels, preferences for PA, role modeling experiences, and motivational reinforcements to be physically active. The PFT met with their assigned participants in bi weekly sessions and followed up with them over the phone weekly to monitor the progress of their individually established goals. The bi weekly sessions were 90 minutes and involved 3 5 interactive activities based on promoting physical a ctivity (specifically aerobic fitness), and healthy nutritional behaviors. Sessions included establishing personal goals with supportive activities designed to be skill building, interactive, enjoyable, and consistent with principles of adult education; em phasizing relevance, active learning, and application of new skills. These educational and skill building activities involved the use of several key theoretical constructs belying S CT including role modeling (observational learning), addressing belief stru ctures (expectations, expectancies), enhancing skills related to PA behavior (behavioral capability), and confidence building (self efficacy). IM Step 5. Planning Program Adoption, Implementation, and Sustainability Builds on streng ths and resources of the community, involves long term commitment to community health promotion, and facilitating partnerships in all phases of were utilized in Step 5 of IM planning for

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97 program adoption, implementation, and sustainability Facil itating partnerships in all phases of research involved coordinating the efforts of academics with policy makers, implementing the health program throughout the fire depart ment. Long term commitment to sustainability of the health program included the collaboration on grant writing efforts between firefighters and academic partners, the use of voluntary involvement of undergraduate and graduate research assistants, and use o f economically viable approaches to promote PA such as creating equipment for PA. The CAP adopted the health program efforts via building upon the strengths of the community regarding the paramilitary structure of the firefighter profession in order to ado pt policies requiring annual CVD screenings, requiring on duty PA, providing funding for training firefighters to become certified as PFT, and for providing environmental modifications to promote PA at each of the fire stations. The CVD program was adopted during the start of the department wide CVD screenings and physical fitness assessments. Firefighters administering the CVD screenings informed firefighters receiving the testing a program to promote PA to reduce risk of CVD was being initiated throughout the entire fire department. Firefighters getting the screenings received information from the PFTs administering the screenings regarding the high rates of CVD in firefighters, the risk factors associated with CVD in firefighters, and the importance of PA especially cardiorespiratory fitness, in preventing CVD in firefighters. After the screenings, firefighters learned quarterly sessions would be held about promoting PA lifestyles and one hour of on duty PA would be required during each shift of work. Fir efighters were also asked to give feedback concerning the type of environmental

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98 modifications they would need to promote PA at their respective fire station. Finally, firefighters were introduced to their co workers who were certified as PFT, and were enco uraged to utilize them as resources for promoting PA behaviors. The peer mentors firefighters took the responsibility to adopt and implement the intervention following the needs assessment. The PFTs embarked on both a department wide initiative and on a s pecific pilot intervention for 24 of the highest risk firefighters based on the results of the WFI assessment. Policy makers were integral in the adoption of the health program because they allocated funds from the fire departments annual budget to compens ate for the 40 hours of training firefighters needed to become certified as a PFT. The time required to become certified as a PFT was in addition to their normal firefighter responsibilities, and was often compensated at overtime pay rates. The CAP acknowl edged paying firefighters for overtime training is costly, and in doing so underscores the long term commitment by the fire fighter policy makers to adopt a sustainable program for promoting PA and preventing CVD in their firefighters. The firefighter poli cy makers making this decision believed greater costs would be incurred in the future without a CVD health program due to increased missed days of work, treating high blood pressure, dislipidemia, and by having to hire new firefighters to replace firefight ers retiring early or going to light duty because of poor physical fitness or risk of CVD. Even with this costs benefits point of view, both the fire fighter policy makers and academics agreed allocating funds for a CVD health program may be unrealistic fo r other fire departments due to budget constraints and the current economic climate. These economic challenges underscore the need for grant and subsidies to adopt, implement, and sustain CVD prevention programs in firefighters

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99 Emphasis on the long term co mmitments was also demonstrated through collaboration between academic partners and the fire department on grant writing efforts to provide additional funding for sustaining the PA and CVD prevention program in their department, and for disseminating it to the broader firefighter population. Federal, state, private, and intramural university level grants are actively being developed and submitted to secure funding for efforts to sustain and improve the current health program, as well as to disseminate simil ar health programs to other fire departments. Sustainability and long term commitment was also fostered by the use of fire fighter centered involvement in the planning, implementation, and evaluation of the CVD intervention. The CAP believed this approach would lead to more involvement, investment, and ownership of by the fire department than expert centered approaches, and thus would lead to long term sustainability. Utilizing low cost strategies (making PA equipment, use of policies, and utilizing unpaid research assistants), are examples of how the intervention could be sustained with minimal economic investments and not be solely dependent upon external grant funding for sustainability. The involvement of unpaid qualified graduate and undergraduate rese arch assistants was integral in capitalizing on the strengths of the academic community, and it also demonstrated a long term commitment by academic partners to firefighter partners. Interdisciplinary graduate and undergraduate students participated in the CAP efforts and their efforts included assistance in training the PFT trainers, validating field based and laboratory based cardiorespiratory fitness in firefighters, and in working as liaisons between the university and firefighters. Use of voluntary res earch assistants contributed towards

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100 reducing costs associated with hiring paid research assistants. Academic research assistants were incentivized by gaining meaningful research experience, experience in health promotion efforts, satisfying academic requi rements (use of interns, practicum hours, receiving course credit for completing research hours), opportunities for co presenting in conferences, and for co authoring manuscripts. IM Step 6 Planning for Evaluation The evaluation step in IM incorporated t facilitates partnerships in all phases of the research process involves system development through iterative and cyclical process, and promotes co It is important to emphasize the evaluation portion of IM is iterative in nature since it was the first step to be undertaken by the CAP when planning the needs assessment, evaluation was used to inform each step of IM, and evaluation guided all aspects of the research process. This iterative process of ev aluation was a critical component in fostering collaboration and facilitating partnerships between the firefighter community and academics. Furthermore, the information produced during from the evaluation process contributed to the co learning experiences between firefighters and academic partners. The following section briefly describes the outcomes from the evaluations of the community wide health program, the pilot intervention, and in validating the WFI sub maximal cardiorespiratory fitness assessment. In addition to the needs assessments, the CAP conducted multiple evaluations including establishing annual CVD screenings, pre and post testing of the CVD intervention on the highest risk firefighters, validating field based assessments of cardiorespirato ry fitness, and conducting health programming evaluations (formative and process evaluations). The CVD screenings used for the needs assessment were

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101 institutionalized and are now used to annually track CVD and physical fitness indicators in firefighters ov er time, for identifying high risk firefighters, to evaluate intervention efforts for high risk firefighters, and to reward firefighters for improving CVD risk factors and physical fitness. Establishing annual CVD screenings is an example of the long term commitment by the CAP to the health of firefighters and is likely to be sustained since firefighters take the lead role in administering the annual CVD assessments, and academic partners take the lead role in the management and analysis of dat a collected f rom firefighters. All 144 firefighters in the department completed the baseline needs assessments to identify high risk firefighters, and 24 firefighters were identified for a high risk sample in the pilot intervention. Table 3 1 describes the pilot sampl e and department wide baseline health measures and shows that the sample recruited for the study were older, had a lower average VO 2 max, and higher body fat composition than the department as a whole. The sample was randomly assigned to intervention and co ntrol groups (n=12 for each group). Baseline equivalence was tested prior to intervention with a paired samples t test on all health factors assessed between the treatment and control groups and revealed both groups were similar (not significantly differen t at the p=0.05 level). Three month and one year follow up testing of the pilot intervention across a broad range of health outcome measures including the WFI sub maximal aerobic capacity assessment, BMI, body fat percentage, hand grip strength, arm and le g strength, push ups, abdominal static plank and a sit and reach test. Statistical analyses using the independent and paired samples t tests examined if health measures significantly changed from baseline to post testing both within and between groups (Tab le 4 4).

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102 Sub maximal aerobic capacity significantly increased from a baseline of 37.38 mlO 2 /min/kg to 39.98 mlO 2 /min/kg at post testing for the intervention group ( p < 0.001) while the control group did not significantly increase VO 2 max (p=0.3838). The cont rol group significantly increased body fat percentages of 28.71% at baseline to 29.53% at post testing (p = 0.044), while the intervention group maintained body fat percentages from 30.48% at baseline to 30.20% at post testing ( p =0.384 ). No significant inc reases or decreases were detected in any of the musculoskeletal health measure in either treatment or control group from baseline to post testing. The efforts in validating the field based cardiorespiratory assessment fostered co learning and capacity buil ding between firefighters and academic partners. The purpose of these efforts was t o evaluate the accuracy of the current WFI sub maximal treadmill test used in firefighters to predict their true VO 2 max with the laboratory based standardized VO 2 max Bruce P rotocol test. Twenty nine firefighters (86% male), completed both the field based WFI sub maximal and laboratory based true VO 2 max tests on two separate occasions. The validation process fostered engagement between academics and firefighters since both col laborated on recruiting firefighters to participate in the study and for administering the tests to firefighters who volunteered to participate. The facilitation of a partnership within the CAP was strengthened in the endeavor to validate the WFI sub maxim al test because firefighters were exposed to a wide variety of academics including faculty, research assistants, and volunteer graduate and undergraduate students. The findings of the validation study produced important information regarding the accuracy of identifying firefighters at risk for on duty CVD. The sub maximal test was

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103 shown to be moderately correlated in its ability to accurately predict the true VO 2 max of firefighters (r=0.635, p = 0.005). A moderate correlation may be considered low for a p hysiologically based prediction test, and is often not acceptable for clinical applications. The sub maximal VO 2 treadmill test underestimated the true VO 2 max in the majority of firefighters (72.4%), and over estimated the true VO 2 max in 24.4% of our sampl e. Participants whose true VO 2 max was overestimated by the WFI submaximal test tended to have a significantly higher body fat composition than those who were underestimated by the WFI protocol. This finding is concerning given the main purpose for using th is test is to identify firefighters at risk for on duty CVD events. A test that over predicts the true VO 2 max of less fit firefighters will not identify those at greatest risk for on duty CVD, and preclude the opportunity to intervene in these high risk fi refighters. The range of VO 2 values and standard deviations between the predicted and trueVO 2 max values varied greatly (35.4 to 50.9 vs. 28.6 to 58.4 mlO 2 /kg/min, and standard deviation of 3.91vs 7.22 respectively). This suggests the prediction formula fo r the sub maximal test compresses theVO 2 max values into a more n arrow range than what is true. This finding is concerning because a firefighter with a low true VO 2 max is likely to produce a higher predicted VO 2 max on the WFI sub maximal test then what is a ctually true, thus limiting the ability of the WFI test to identify firefighters who are at a high risk for CVD. This co learning process led both firefighters and academics to conclude further research is needed to validate this sub maximal test in firefi ghters of varying fitness levels (most firefighters who participated were relatively physically fit), with a larger sample size including more female participants, in a wider range of age groups, and in more ethnically diverse populations.

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104 Involving system s development through iterative and cyclical process was operationalized by conducting programming evaluations on the department wide health program and pilot intervention Academic partners provided consultation to firefighters on how to conduct formative and process evaluations for assessing the development and implementation of the health program. The PFT and fire chief gathered formal and informal feedback from their own perspectives regarding the quality of program planning and development. The PFTs as sessed the formative phase of the intervention including tracking the recruitment and participation rates of high risk firefighters into the intervention, assessing the quality of peer training, and assessing the quality of activities and equipment being d eveloped for the intervention. This information was used to maintain, modify, and eliminate strategies used in the intervention efforts. The PFTs conducted process evaluations via tracking the fidelity, dosage delivered and reached for the throughout the implementation of the CVD health program and pilot intervention. The PFT kept and tracked attendance records for the one to one counseling sessions for high risk firefighters, for the quarterly department wide health education classes, and for meetings hel d with fire administrators to advocate for policy and environmental changes within the department to promote PA. The PFT also monitored participation and adherence rates for the mandatory on duty PA at each of the fire stations. Feedback from firefighters collected during the process evaluations contributed to informing strategies used by the PFT including: the importance of addressing social norms regarding aerobic exercise held by firefighters, utilizing functional training exercise, and tailoring exercis e prescriptions based on individual characteristics (fitness level, motivation for PA, preference for various forms of PA).

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105 Discussion To our knowledge, this is the first study to apply principles of Community Based Participatory Research towards health p romotion efforts in firefighters. From our experience, we believe Intervention Mapping and utilizing the orientation and principles of CBPR is a useful model for developing, implementing and evaluating health promotion programs for firefighters. The overla pping core concepts between IM and CBPR (Table 2 3) may account for the synergy of integrating these approaches to health promotion in firefighters. Both IM and CBPR are guided by similar conceptual frameworks concerning health promotion efforts including: involving the participation of the community in all phases of research, utilizing the ecological approach towards understanding and intervening upon health outcomes, developing capacity via capitalizing on assets within the community, and in using an iter ative process in program development, implementation and evaluation. The congruency of these concepts complemented the efforts of integrating the systematic and well structured methods of IM with the orientation of CBPR. Actively involving the community i n all stages of the research project and providing direct benefit to the community being studied makes CBPR and IM an attractive research model for health promotion in firefighters. Firefighter communities are distinguished by unique socio culture characte ristics that make CBPR an appealing approach to PA intervention efforts. Firefighters rely heavily upon cohesive team work, are present in the work environment for long periods of time ( 24 hour work shifts), operate under a communal structure, have access to shared resources, are influenced by similar environmental factors, and are governed paramilitary policies concerning conduct and behavior.

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106 The core process of IM advocates for the use of logic models involving an ecological approach to health promotion, and a principle for CBPR emphasizes applying an ecological approach towards understanding and intervening upon multiple determinants of health. Use of the ecological model was operationalized in this study when it was used to guide the process for the lit erature review conducted in S tep 1 the needs assessment and in S tep 2 of IM developing matrices of change objectives for the individual, interpersonal, environmental, and policy level factors for promoting PA in firefighters. Individual level determinants were identified and intervened upon including developing self efficacy for PA via observational learning from peer mentors, building capabilities to perform PA, and reinforcements to foster positive expectancies to perform PA. Interpersonal level factors i ncluded identifying and training peer mentors to promote department wide PA and for one on one counseling for high risk firefighters. Interpersonal factors also included advocacy efforts to fire administrators to create policy and environmental modificatio ns for prom oting PA in firefighters. Policy factors included institutionalizing annual C V D screening and physical fitness assessments, requiring on duty PA during each shift of work, and requiring attendance for quarterly health education sessions. Environ mental factors were addressed by taking an inventory of workout areas at each fire station and modifications were made to improve access to exercise by building fitness equipment and acquiring low cost equipment for functional training. Developing capacit y via capitalizing on assets within the community was integral in the success of collaborative efforts in the CAP and in the development, implementation, and evaluation of the health programs. Using role model firefighters to serve as peer

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107 mentors was inte PA, and was believed by all those involved this approach was much more effective than if it would have been delivered by non builds upo n the team centered culture that is inherent in the firefighter profession. Utilizing firefighters for the evaluations process in administrating physical fitness and CVD screenings capitalized on their expertise and knowledge in conducting medical based as sessments (measuring blood pressure, heart rate, etc.). Building upon their paramedic skills is particularly useful for this type of data collection when evaluating firefighter health. Empowering firefighters to take charge of these types of evaluations al so increases the likelihood of sustaining regular physical fitness and CVD screenings for the long term. The implementation and adherence to policies regarding PA builds upon the strength of the paramilitary nature of the firefighter profession that regula tes conduct and behavior. The iterative process of health program development was a commonly used core concept shared by IM and CBPR. Examples of how the iterative process was utilized included applying evaluations throughout each step of IM. Although eva luation is Step 6 of IM, it was the first process to be undertaken, it was critical for developing the needs assessment (Step 1), informing the objectives created for the matrices of change (Step 2), and was essential for conducting formative and process h ealth program evaluations and led to modifying strategies undertaken during program development and implementation (Steps 4 and 5 respectively). The informed selection of theory (Step 3) began when the matrices of change were being developed. Identifying S ocial Cognitive Theory to serve as the underpinnings for the health program during Step 2 was

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108 essential for guiding the development of performance and change objectives. The iterative process also occurred when a second wave of matrices of change objective s were created during program development (Step 4). The second wave of matrices of change was created after the PFT were recruited and were developed based on the 40 primarily focused on developing specific strategies and methods on how they intended to implement and evaluate their peer based program to the entire fire department and to the high risk firefighters. Limitations It can be argued that the strengths of Interventio n Mapping also represent its weaknesses. The theory and evidence based intervention development of IM is a complex and time consuming process. Needs assessments, creation of the matrices of change objectives and performance objectives, and the process of evaluations is particularly time consuming. Intervention Mapping is typically applied to simple and uni dimensional behaviors, and can become overwhelming when applied to multi dimensional behaviors, such as physical activity ( McEachan, et al., 2008 ) Additionally, the comprehensive development involved with integrating IM with CBPR was not fun ded in this study and may not be a feasible for other fire departments to take on these efforts without university or academic supports. Funding for development and demonstration grants is often limited for this phase of the research process and is typical ly not given sufficient consideration prior to implementation of an intervention. This may help to explain why many interventions lack the use of planning models and are often not theoretically grounded or evidence based ( McEachan, et al., 2008 )

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109 The nature of Community Based Participatory Research is also time consuming and challenging. Examp les of these efforts include; identifying and networking with gatekeepers and key informants; building partnerships; developing community capacity; leveraging material and human resources; training of community and academic program planners; and developmen t of a comprehensi ve iterative evaluation plan. For example, it took over half a year to network with firefighters before a CAP could be formally established, another half year before a needs assessment was conducted, and before the department wide and hig h risk interventions were launched and evaluated (2 years of total networking and planning). This time consuming process o f community based research does not lend itself to high rates of multiple publication, and on top of not often being a fundable aspect to the research process, often precludes researchers from getting involved who are interested in tenure track faculty positions. Despite the time consuming nature of the CBPR and the IM protocol, we believe it allowed us to create a comprehensive interv ention package that was tightly focused and theory based. Studies show interventions using planning models that are grounded in health theory to be more efficacious and effective than those that are not. Additionally, health promotion efforts utilizing CBP R are more likely to be sustainable. Furthermore, the comprehensive iterative evaluation of IM provides critical information as to the formative, process, impact, and outcome evaluations of the intervention. Formative and process evaluations can lead to ch anges that need to take place during the development or implementation of the intervention to improve success. Further, these evaluations can be used to identify the program components that are attributable to the impacts and outcomes of the intervention. These formative and summative evaluation

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110 results are critical to addressing threats to the internal and external validity of the entire research project. The proposed studies are among the first efforts to describe the participatory process of community d riven health promotion research in firefighters, to validate the current cardiorespiratory fitness assessment used to measure cardiorespiratory fitness of firefighters, and to pilot test the use of theory driven ecological strategies to reduce CVD risk fac tors in firefighters. Further research is needed to assess the utility of engaging academics with local firefighters to reduce CVD and promote health in other geographic locations, studying the effectiveness of integrating CBPR with other planning models, and to study community based approaches to health promotion in other diverse firefighter communities, study utility of CBPR for promoting other health issues such as nutrition, stress management behaviors, alcohol, tobacco or other drug behaviors in firefi ghters.

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111 Table 2 1. Definitions for the p rinciples of c ommunity based p articipatory r esearch Principles of CBPR Description Respects and recognizes community as a unit of identity The community is a group of individuals who share some common interests, va lues, goals, politics, and characteristics Builds on strengths and resources in the community Researchers use the resources that are internal to the community when possible Facilitates collaborative, equitable involvement of all partners in all pha ses of research All members of the team will be informed about, and included in, all aspects of the research process Integrates co learning of knowledge and intervention for mutual benefit of all members Information desired by the community will be con sidered integrated with the create positive change for the community Balance of research and action via information and learning are shared equally by all members All parties learn equally from each other as everyo ne shares their ideas, perspectives and expertise Involves a cyclical and iterative process All phases of the research process may be refined as each community adds its insight Addresses research topics from both positive and ecological perspective s Addresses the whole system and emphasizes outcomes that are beneficial to the health, happiness, and success of the community Disseminates findings and knowledge gained to all partners Research findings are communicated to the academic and research s ocieties and to the communities in ways that are most useful for each Involves a long term commitment by all partners The goals of the project should take the future welfare of all parties into consideration

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112 Table 2 2. The s teps of Intervention Mapp ing Step Description of a ction End p roduct 1. Needs a ssessment Assess the health problem, its related behaviors and environmental conditions, and their associated determinants for the at risk population A description of a health problem, its impact on qua lity of life, and determinants of behavioral and environmental causes 2. Define program o bjectives Provides the foundation for the intervention by specifying who and what will change as a result of the intervention A set of matrices that combines perf ormance objectives at each ecological level with select determinants to produce change objectives 3. Selection of m ethods and s trategies Seek theory informed methods and practical strategies to effect changes in the individual behaviors and the envir onment Organize and operationalize the intervention methods 4. Program design and production Pilot testing of program strategies and materials with target audience Completed program materials and protocols 5. Program adoption, implementation, an d sustainability Matrix development linking adoption and implementation performance objectives to personal and external determinants A detailed plan for accomplishing program adoption and implementation by influencing behavior of key individuals or groups 6. Process and outcome evaluation Finalize an evaluation plan A plan for analyzing the anticipated changes in health outcomes

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113 Table 2 3. Integrating CBPR p rinci ples with Intervention Mapping s teps Steps for I ntervention Mapping CBPR p rinciple s 1 2 3 4 5 6 Builds on strengths and resources of community X X X X Facilitates partnerships in all phases of research X X X X Promotes co learning and capacity building X X X X X Emphasizes local releva nce and ecological perspective of multiple determinants of health outcomes X X X Involves system development through cyclical and iterative process X X X X Involves long term process and commitment X Step 1=Needs a ssessme nt Step 2= Developing m atrices of c hange objectives Step 3= Theory Step 4=Development of p rogram Step 5= Program adoption and i mplementation Step 6= Program e valuation

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114 CHAPTER 3 VALIDATION OF A CARD IORESPIRATORY FITNES S ASSESSMENT IN FIREFIGHTERS Backgro und Cardiovascular disease (CVD) constitutes the leading cause of on duty death and disability in firefighters, contributing to 45% of on duty fatalities annually ( Duenas Laita, et al., 2007 ; National Institute for Occupational Safety and Health, 2001 ; United States Fire Service & National Fire Data Center, 2002 ) The majority of fatal and non fatal CVD events in firefighters occur during prolonged bouts of strenuous exertion including: suppressing a fire (32.1%), physically demanding non emer gency duties (15.4%), responding to an alarm (13.4%), and performing training exercises (12.5%) ( Kales, et al., 2007 ) A high level of physical fitness is essential for firefighters given near maximal heart rates are achieved and sustained for prolonged periods of time during these on duty tasks, they are often performed wh ile using heavy equipment, and in extreme temperatures ( Geibe, et al., 2008 ; Holmer & Gavhed, 2007 ; Rossi, 2003 ) Therefore, the relationship between physical fitness and CVD during the performance of firefighting duties has received considerable attention among concerned firefighters, public health officials, and re searchers ( Leiba, et al., 2011 ; National Institute for Occupational Safety and Health, 2001 ; Poston, et al., 2011 ; United States Fire Service & National Fire Data Center, 2002 ) Components of physi cal fitness include cardiorespiratory fitness, body composition, muscular endurance, muscular strength, and flexibility. Among these, cardiorespiratory endurance is proving to be the most important component of physical fitness related to on duty CVD in fi refighters ( Harvey, et al., 2008 ; Leiba, et al., 2011 ; Rhea, et a l., 2004 )

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115 2 during maximal or exhaustive exercise. It reflects the physical fitness of the individual an d is measured in milliliters of oxygen used in one minute per kilogram of body weight (mlO 2 /min/kg) ( Powers & Dodd, 2003 ) A low VO 2 max is a primary risk factor for premature mortality and morbidity due to CVD ( Haskell, et al., 2007 ; Peterson, et al., 2008 ; Sui, et al., 2006 ) A longitudinal cohort design study, controlling for BMI, found individuals who could not achieve 85% predicted VO 2 max had significantly more fatal and nonfatal myocardial infarctions, unstable angina, and hypertension than those who could achieve 85% predicted VO 2 max ( P. N Peterson, et al., 2008 ; Sui, et al., 2006 ; Sui, et al., 2007 ) A recent prospective study of over 25,000 asymptomatic men demonstrated that low VO 2 max exe rcise tests are highly predictive of subsequent cardiac death, and the association increases for each additional CVD risk factor present ( Sui, et al., 2006 ; Sui, et al., 2007 ) Research shows VO 2 max may be one of the most important biological factors related to CVD in firefighters, and is believed to be an even stronger predictor of fatal and nonfatal CVD in firefighters than obesity ( Harvey, et al., 2008 ; Leiba, et al., 2011 ; Poston, et al., 2011 ; Rhea, et al., 2004 ; D. L. Smith, et al., 2001 ) Rates of substandard VO 2 max are shown to be highly prevalent among the firefighter population as studies find 25% of firefighters fail to achieve the current minimum standard VO 2 max of 42.0 mlO 2 /kg/min in firefighters ( Harvey, et al., 2008 ; International Association of Firefighters, 2009 ; Mier & Gibson, 2004 ) In addition, a substandard VO 2 max is significantly associated with the presence of other CVD risk factors in firefi ghters such as obesity

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116 and hypertension, thus compounding the likelihood of CVD in firefighters ( Donovan, et al., 2009 ; Poston, et al., 2011 ) The strong relationship between VO 2 max and CVD has led firefighters and researchers to advocate for the development of a validated cardiorespiratory endurance test to be periodically administered to firefighters in order to identify those who are at risk for CVD ( Donovan, et al., 2009 ; Harvey, et al., 2008 ; Poston, et al., 2011 ) In addition, a validated VO 2 max exercise test can help to identify a healthy VO 2 max standard for protecting firefighters against CVD ( Geibe et al., 2008 ; Mier & Gibson, 2004 ; Williams Bell, Villar, Sharratt, & Hughson, 2009 ) Discrepancy currently exists among researchers and profes sional firefighters regarding a healthy VO 2 max standard for aerobic fitness of firefighters. Recommended VO 2 max values for firefighters from previous research vary greatly and range from 33.5 to 51.0 mlO 2 /kg/min ( Harvey, et al., 2008 ; Holmer & Gavhed, 2007 ; Mier & Gibson, 2004 ; Sothmann, et al., 1990 ; Williams Bell, et al., 2009 ) The inconsistency for a recommended VO 2 max standard from previous research is largely due to these studies utilizing various fo rms of protocols to measure VO 2 max ( Bilzon, Scarpello, Smith, Ravenhill, & Rayson, 2001 ; Harvey, et al., 2008 ; Henderson, Berry, & Matic, 2007 ; Mier & Gibson, 2004 ; Sothmann, Gebhardt, Baker, Kastello, & Shepp ard, 2004 ; vonHeimburg, KRasmussen, & Medbo, 2006 ) For instance, previous methods for determining VO 2 max values in firefighters have evolved over time and included the Gerkin treadmill protocol a nd Balke treadmill protocol ( Mier & Gibson, 2004 ; Sothmann, et al., 1990 ) The gold standard for measuring VO 2 max is by direct measurement of exhaled gases during exercise and involves laboratory based equipment, such as metabolic

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117 carts and gas exchange anal yzers, and incrementally brings the subject up to maximal exertion in a stage based test. This type of VO 2 max testing is normally not feasible for fire departments to administer because it is costly, generally lacks portability, and is thus unrealistic for administering in the field on a large scale. The governing body for firefighter fitness known as the Fire Service Joint Management developed the Wellness and Fitness Initiative or WFI ( International Association of Firefighters, 2009 ) which currently uses a sub maximal treadmill test based on the time to reach 85% of age predicted maximal heart rate to e stimate the true VO 2 max of firefighters. To date, the WFI sub maximal test has not been validated in the scientific literature. The need to accurately assess VO 2 max in firefighters is critical given the high rates of on duty CVD deaths and disabilities i n firefighters. A validated aerobic capacity assessment will help to identify those at greatest risk for an on duty CVD related event and provide the opportunity for intervention. Further, it can help to set an accurate healthy VO 2 max standard, and can be used to accurately evaluate health promotion efforts aimed at increasing the VO 2 max of firefighters. Therefore, the purpose of this study is to evaluate the validity of the current WFI sub maximal treadmill test to predict the true VO 2 max of firefighters o btained from the laboratory based maximal Bruce Protocol. This study hypothesized that the WFI sub maximal VO 2 max protocol under predicts the true VO 2 max in more fit firefighters and over predicts the true VO 2 max in relatively less fit firefighters. Or, in other words, it compresses the true VO 2 max values into a more narrow range than what actually exists. Methods Thirty firefighters from a North central Florida fire department voluntarily completed both the WFI sub maximal prediction and true VO 2 max tests on two separate

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118 occasions. The sample was comprised of 86% male and 14% females (department wide average of 89% male and 11% female), thus the sample population accurately represents the gender mak e up of the department tested. Participants first complete d the WFI sub maximal test, followed by the Bruce protocol on the following week. Institutional Review Board approval was obtained for this study and participants completed the informed consent process prior to testing wherein the protocols, risks, and ben efits for the study were disclosed. No incentives we re provided for participation. All participants completed health screenings prior to aerobic testing including: height, weight, body mass index, percentage body fat, blood pressure, and pre exercise heart rate. A 3 point skin fold measure was used to measure percentage of body fat. In addition to the health screenings, participants also completed a survey on information including: age, gender, stage of motivation to participate in regular physical activity and frequency, intensity, and duration of weekly physical activity participation. Table 3 1 compares the sample mean demographic and physical fitness variables of the participants with those from the entire department they were sampled from for this stud y. Overall, the participants were on average 7 years younger (38.5 vs. 31.9 YO) roughly equivalent in gender (89% vs. 85.2% male), slightly higher body fat percentage (25.96% vs. 22.24% body fat), and slightly higher submaximal predicted VO 2 max (44.58 vs. 42.91 mlO 2 /kg/min) than the population from which they were sampled. The participants reported an average of 4.6 days/week of moderate to strenuous physical activity lasting on average 40 minutes per session. There was no attrition or dropout from the samp

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119 discarded due to mechanical issues with the equipment that arose during testing giving invalid results, thus the final sample size was 29 participants. WFI Sub maximal Test The WFI sub maximal test predicts VO 2 maxof firefighters based upon the amount of time it takes to reach 85% of estimated maximal heart rate (HR max ), during a graded treadmill protocol. The sub maximal test uses the age predicted estimation of HR max thus the formula t o calculate 85% of HR max = (220 age) x 0.85. The amount of time it takes to achieve 85% of HR max (test time), and BMI is inserted into the following formula to predict true VO 2 max: VO 2 max = 56.981 + (1.242 x test time) (0.805 x BMI) ( International Association of Firefighters, 2009 ) The WFI sub maximal test begins with a 3 minute warm up at a speed of 3.0 mph at a 0% grade, followed by 1 minute stages of alternating increases in speed and incline of the treadmill. For example, after the 3 warm up, treadmill speed is increased to 4.5 mph, at 4 minutes the incline of the treadmill is raised to a 2% grade, at 5 minutes the speed is increased to 5.0 mph, at 6 minutes the treadmill is raised to a 4% grade. Each of the subsequent stages of the WFI protocol last 2 minutes and alternate between a 0.5 mph increase in speed and 2% incline of the treadmill until 85% o f HR max is reached and maintained for 15 consecutive seconds. Afterwards, participants complete a cool down phase consisting of walking for 3 minutes at 3 mph at a 0% grade. Recovery heart rate was recorded during the first minute of the cool down phase. A ppendix B describes the stages for the first 10 minutes of the WFI sub maximal protocol. Bruce Protocol (Maximal VO2 T est) Prior to administering the Bruce protocol, electrocardiogram (EKG) and metabolic cart gas exchange analyzers were calibrated to prop er settings according to

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120 manufacturer instructions. A 12 rate prior to testing, throughout the duration of the test, and for 5 minutes following the completion of the test. A standard mouthpiece and nose clip were assembled and calibrated to the metabolic cart in order to accurately measure the amount of oxygen consumed and carbon dioxide exhaled by participants. Each part icipant was hooked up to an electrocardiogram machine and monitored for EKG abnormalities during the assessment. Participants walked for 3 minutes at 2.5 miles prior to administration of the Bruce protocol to familiarize themselves with using the treadmill Participants were instructed to exercise as long as possible during the Bruce protocol, which involves successive 3 minute stages of increasing speed and incline of the treadmill over time (Appendix C describes the stages of the Bruce protocol). Rate of Perceived Exertion (RPE), according to the Borg scale ( Borg, 1982 ) was recorded twice during each 3 minute stage (once at the start of a stage and once at the end of a stage). Criteria for terminating the test included the parti cipant discontinuing the test at any time due to fatigue or any other reason, a plateau in VO 2 reached, or when two out of the following three criteria are met: 1) reaching maximum heart rate (HR max = 220 age), 2) achieving a respiratory exchange ratio (RE R) greater than 1.15 or 3) reporting a RPE of 20. After completion of the Bruce protocol, participants walked for a recovery period of at least 5 minutes while heart rate and RPE were recorded at the one, three, and five minute time points. Data Analyses All statistical analyses were performed using SAS version 9.2 software (SAS Institute Inc., Cary, NC, USA). Mean differences between the department population

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121 and the participants were analyzed with independent samples t tests to check f or equivalence bet ween groups. Pearson correlation coefficients were calculated to examine the relationship between the predicted WFI sub maximal values to the true VO 2 max values obtained from the Bruce protocol. Additionally, Pearson correlations coefficients were obtained to determine if there was a relationship between demographic and physical fitness variables to the true VO 2 max values obtained from the Bruce protocol ( = 0.05). Additionally, participants results were divided into two categories as true VO 2 max being over vs. under predicted by the WFI test and the hypothesized predictor variables of exercise frequency/intensity, BMI, and body fat were tested as predict ors for classification into either group. Results All participants completed both the sub maximal and maximal VO 2 testing, and each participant achieved the criteria for maximal effort during the Bruce protocol. Mean values and standard deviations from th e 2008 WFI sub maximal and Bruce protocol are presented in Table 3 2. The estimated sample mean values for the sub maximal VO 2 and true VO 2 max values from the Bruce Protocol were similar (44.583.91 mlO 2 /kg/min and 45.687.22 mlO 2 /kg/min respectively, pair ed t test p value = 0.2616). Though the means are similar, the ranges of mean values and standard deviations differed between the predicted and true VO 2 max values (min max: 35.4 to 50.9 mlO 2 /kg/min vs. 28.6 to 58.4mlO 2 /kg/min, and standard deviation of 3 .91vs 7.22 respectively). These results show the prediction formula compresses VO 2 max values into a more narrow range than what is true. Additionally, the 2008 WFI sub maximal test under predicted the true VO 2 max in 72.4% of firefighters, and over predicte d in 27.6% of the firefighters tested (Table 3 3). Further analysis showed the group whose VO2max was over predicted by

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122 the WFI sub maximal test had a higher mean body fat percentage compared to those who were under predicted (p=0.0157). Pearson correlati on analyses between the WFI sub maximal and Bruce protocol produced a significant and moderate correlation coefficient (r=0.635, p = 0.005). True VO 2 max values were significantly and moderately correlated with percentage body fat (r= 0.7353, p=0.0001 ), d iastolic blood pressure (r= 0.541, p =0.0035), BMI (r= 0.5445, p=0.0033), one minute recovery HR (r=0.537, p=0.0038), and body composition (r= 0.5178 p=0.0080 ) (Table 3 4). Discussion The purpose of this study was to examine the ability of the WFI sub m aximal VO 2 test to accurately predict the true VO 2 max of individual firefighters. The sub maximal test was shown to be moderately correlated in its ability to accurately predict the true VO 2 max of firefighters(r=0.635, p = 0.005). A moderate correlation ma y be considered low for a physiologically based prediction test and is potentially unacceptable for clinical applications. Additionally, the range of VO 2 values and standard deviations between the predicted and trueVO 2 max values varied greatly (35.4 to 50. 9 vs. 28.6 to 58.4 mlO 2 /kg/min, and standard deviation of 3.91vs 7.22 respectively). This suggests the prediction formula for the sub maximal test compresses theVO 2 max values into a more narrow range than what is true. This finding is concerning because a firefighter with a low true VO 2 max is likely to produce a higher predicted VO 2 max on the WFI sub maximal test then what is actually true, thus limiting the ability of the WFI test to identify firefighters who are at a high risk for CVD. Given that the purp ose of this test is to track test that can significantly over or under predict individual values should be examined

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123 carefully for its applicability and place in a fi tness assessment for a population that is especially vulnerable to on duty CVD events. Although the sample means for the sub maximal and Bruce VO 2 max protocols were similar, the sub maximal VO 2 treadmill test underestimated the true VO 2 max by as much as 21.1% in the majority (72.4%) of the participants, and over estimated the true VO 2 max by as much 30.6% in our sample. Participants whose VO2max values were over predicted by the WFI test were significantly more likely to have a higher body fat percentage t han those who were under predicted by the test. This finding is concerning given the main purpose for using this test is to identify firefighters at risk for on duty CVD events. A test that over predicts the true VO 2 max of firefighters may fail to accurate ly identify those at greatest risk for on duty CVD, and thus preclude the opportunity to intervene in these high risk firefighters. One issue may be that variances in individual body composition and metabolic characteristics may impact the estimated values Another explanation that may account for the under and over estimation of VO 2 max is the use of age estimated HR max used in the WFI sub maximal formula to predict true VO 2 max. Age estimated HR max (HR max = 220 Age) has been shown to vary from true HR max by +/ 10 12 beats per min among individuals ( American College of Sports Medicine, 2000 ) True VO 2 max values were found to be significantly and strongly correlated with percentage body fat (r= 0.7353, p=0.0001), and moderate ly correlated with other physiological measures: diastolic blood pressure (r= 0.541, p =0.0035), BMI (r= 0.5445, p=0.0033), one minute recovery HR (r=0.537, p=0.0038), and body composition (r= 0.5178 p=0.0080). This finding may be useful for improving the accuracy of the WFI

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124 sub maximal test in predicting the true VO 2 max of firefighters. Assessing indicators such as percentage body fat, resting diastolic blood pressure, and one minute recovery heart rate in conjunction with the WFI sub maximal test may hel p identify less fit firefighters who are producing overestimated VO 2 max values. Caution should be used in the interpretation of these results as there are several limitations to this research. First, the sample size in this study was small (n=29). In light of this limitation, this is the only VO 2 max validation study to our knowledge using a sample entirely comprised of active duty firefighters. Typically, firefighters only make up a small percentage of the sample in VO 2 max validation studies, wherein all or the majority of the sample is often comprised of non firefighters ( Mier & Gibson, 2004 ) The sample of female firefighters was also small. However, the sample size of females in our study (15%) is inherent in the actual firefighter profession (national average of 4% female) ( U.S. Department of Labor: Bureau of Labor Statistics, 2011 ) Another limitation of our study is the majority of firefighters who participated had a slightly higher estimated VO 2 max than the average from within the department they were sampled (see Table 3 1). No incentives were offered when recruiting firefighters, so most firefighters who voluntarily participated were generally fitness conscious a nd more inclined in knowing their level of physical fitness in terms of true VO 2 max. Offering incentives in future studies may help increase recruitment and participation of less fit firefighters. Another demographic limitation is that the average age of t he sample was lower than the department average. This was in part due to study exclusion criteria of ages >45 years old due to concerns with the intensity of the true maximal aerobic test potentially triggering a cardiac event during testing. Future resear ch is needed to

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125 validate the WFI sub maximal VO 2 test with a larger sample size of actual firefighters, especially for female firefighters, and in firefighters of varying fitness levels. A validated aerobic capacity assessment will help to identify firefig hters at greatest risk for CVD, provide opportunity for intervention, it can help to set an accurate healthy VO 2 max standard for firefighters, and can be used to accurately evaluate health promotion efforts aimed at increasing the VO 2 max of firefighters. T o our knowledge, this is the first study to validate the current WFI sub maximal VO 2 protocol in a pure firefighter population. The ease in which the WFI sub maximal test can be administered and calculated in the field makes it a feasible and attractive as sessment for measuring VO 2 max in firefighters. Additionally, the sub maximal nature of this test makes it less risky than maximal based protocols. However, our results show the accuracy of the WFI sub maximal test in predicting true VO 2 max in firefighter i s questionable and may fail to duty CVD, particularly those with a higher percentage of body fat. Additional improvements to the current WFI protocol should be considered and could include incorpor ating the assessment of percentage body fat, diastolic blood pressure, and one minute recovery heart rate following the completion of the sub maximal test. However, at this time and in its current form, a feasible and validated field based VO 2 max assessmen t is needed to accurately reflect the true VO 2 max of individual firefighters.

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126 Table 3 1. Descriptive characteristics and h ealth s creening i nformation VO2 sample Department Variable m ean (std dev) m ean (std dev) Gender (% male) 85.2 89 Age (yrs) 31.9 3 (6.426) 38.5 (9.6) Bodyf Fat (%) 25.96 (6.387) 22.2 (6.523) BMI 27.204 (3.787) N/A Sub m ax VO2 44.580 (3.912) 42.917 (5.402) Table 3 2. Simple s tatistics: Bruce protocol vs. WFI S ub maximal P rediction T ests Variable Mean Std d ev Min v alue Max v alue Bru ce VO2m ax 45.68 7.22 28.6 58.4 Submax VO2 44.58 3.91 35.4 50.9 Table 3 3. WFI S ub maximal P rediction T est c o mpared to Bruce VO 2 max p rotocol Direction N Mean Std d ev Min Max Under predicted 21 3.887 3.13 0.3 11.1 Over predicted 8 5.878 4.97 0.5 13.75

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127 Table 3 4. Correlation of p redictor variables with Bruce VO2max v alue Variable Pearson correlation coefficient p value WFI s ub max prediction test* 0.6348 0.005 Age 0.2639 0.1834 Body f at** 0.7353 <0.0001 BMI* 0.5445 0.0033 Body c ompositio n* 0.5178 0.0080 Resting HR 0.1303 0.5182 Recovery HR 1 min* 0.5373 0.0038 Recovery HR 3 min 0.3662 0.0603 Recovery HR 5 min 0.2403 0.2473 Resting systolic blood pressure 0.201 5 0.3158 Resting diastolic blood pressure* 0.541 2 0.0035 Exercise d ay s / week (mod strenuous) 0.2652 0.2104 Exercise duration (mod stren uous ) 0.1628 0.4473 Strenuous d ays 0.0972 0.6514 Strenuous duration 0.1879 0.3793 Moderate d ays 0.2688 0.1939 Moderate d uration 0.0004 0.9985 significant at p<0.05 level; ** signi ficant at p<0.001 level

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128 CHAPTER 4 EFFICACY OF A CARDIO VASCULAR DISEASE INT ERVENTION FOR HIGH RISK FIREFIGHTERS: A PILO T STUDY Background Cardiovascular disease (CVD) is the leading cause of on duty death and disability among firefighter populations, acc ounting for 46% of all fatalities and injuries annually ( Duenas Laita, et al., 2007 ; National Institute for Occupational Safety and Health, 2001 ; United States Fire Service & National Fire Data Center, 2002 ) In contrast, CVD is responsible f or 22% of fatalities in police, 10% in emergency medical service workers, and 11% of all deaths in the general work force ( Maguire, et al., 2002 ) The disproportionately high rates of death and disability due to CVD among firefighters have produced urgent calls from concerned firefighters and public health officials to address this issue ( National Institute for Occupational Safety and Health, 2001 ; Rosenstock & Olsen, 2007 ; United States Fire Service & National Fire Data Center, 2002 ) Recent research has identified several specific risk factors for CVD events in firefighters ( Leiba, et al., 2011 ; Poston, et al., 2011 ; Soteriades, et al., 2008 ) and is providing critical insigh t towards the development, implementation, and evaluation of health programs aimed at reducing these risk factors in firefighters ( Bjerk, 2011 ; Elliot, et al., 2007 ) The majority of CVD deaths and disabilities in firefighters occur during s trenuous bouts of physical exertion ( Kales, et al., 2007 ) ; suppressing a fire (36%), performing physically demanding non emergency duties (15%), responding to an alarm (13%), and engaging in physical training (12%). During these conditions, firefighters often work at near maximal heart rates for prolonged periods of time, un der the stress of heavy equipment, and in the presence of high temperatures ( Glendhill & Jamnik, 1992 ; Holmer & Gavhed, 2007 ; Rossi, 2003 ) Therefore, the relationship between physical fitness and

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129 risk of CVD events during the performance of firefighting duties has received considerable attention from researchers ( Leiba, et al., 2011 ; National Institute for Occupational Safety a nd Health, 2001 ; Poston, et al., 2011 ; United States Fire Service & National Fire Data Center, 2002 ) Several physical fitness ris k factors are shown to be related to CVD events in firefighters and include poor cardiorespiratory endurance (also referred to as VO2max or aerobic capacity), having a high percentage of total body fat, having an overweight or obese Body Mass Index classif ication (BMI), having poor musculoskeletal fitness profiles, hypertension and dyslipidemia ( Baris, et al., 2001 ; Glendhill & Jamnik, 1992 ; Haas, et al., 2003 ; Holmer & Gavhed, 2007 ; Kales, et al., 2007 ; Kales, et al., 2003 ; Leiba, et al., 2011 ; Poston, et al., 2011 ; Rosenstock & Olsen, 2007 ; Soteriades, et al., 2008 ) Studies show 25% of all firefighters fail to meet the minimum recommended cardiorespiratory endurance (VO2max) standard of 42.0 ml/kg/min thought necessary to safely perform firefighter duties ( Harvey, et al., 2008 ) Res earch finds 90% of all CVD fatalities occurred in firefighters who were classified as being either overweight or obese ( National Institute for Occupational Safety and Health, 2001 ; United States Fire Service & National Fire Data Center, 2002 ) This is concerning since several studies show 53% of all firefighters are overweight, 35% are obese, 2.5% are extremely obese, and only 12% of firefighters have a healthy body fat percentage or BMI ( Clark, et al., 2002 ; Fahs, et al., 2009 ; Yoo & Franke, 2009 ) A high prevalence of having more than one of these CVD risk factors exists in firefighter populations ( Mier & Gibson, 2004 ; Rhea, et al., 2004 ) Many incumbent firefighters and even new firefighter recruits are commonly found to be overweight and have low to normal aerobic capacities ( Clark, et al., 2002 ;

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130 Kales, et al., 2007 ; Poston, et al., 2011 ) needed to safely perform physically demanding on duty tas ks ( Donovan, et al., 2009 ; Leiba, et al., 2011 ; Poston, et al. 2011 ) A large body of evidence shows regular aerobic Physical Activity (PA), is a protective factor against developing CVD as it increases VO2max, is a critical component in reducing body fat, increasing musculoskeletal fitness, and is shown to both prevent and manage hypertension and cholesterol levels ( Haskell, et al., 2007 ; Kesanniemi, et al., 2001 ; Sui, et al., 2006 ; Sui, et al., 2007 ) Regular PA is also necessary to develop the physical fitness required to safely meet the strenuous demands on duty tasks most commonly linked to CVD events in firefighters ( Harvey, et al., 2008 ; Poston, et al., 2011 ; D. L. Smith, et al., 2001 ) Therefore, researchers, public health officials, and concerned firefighters are advocating for programs promoting regular PA and physical fitness to reduce CVD risk in firefighters ( Kales, et al., 2007 ; MacKinnon, et al., 2010 ; National Institute for Occupational Safety and Health, 2001 ) However, most fire departments do not require firefighters to exercise regularly ( Kales, et al., 2007 ; Kales, et al., 2003 ) Approximately 70% of fire departments lack programs promoting PA or cardiovascular health, do not require firefighters to exercise on duty, do not require incumbent firefighters to maintain physical fitness standards, and do not require routine physical fitness examinations to screen for CVD risk factors ( Geib e, et al., 2008 ) Additionally, little evidence based research exists regarding the evaluation of PA health promotion programs as a means to increase physical fitness or to reduce CVD risk factors in firefighters ( Elliot, et al., 2007 ; Geibe, et al., 2008 ; Kales, et al., 2003 ; MacKinnon, et al., 2010 ; Poston, et al., 2011 ) The lack of programs and studies promoting PA in firefighters underscores the need for researchers and firefighter

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131 communities to collaborate on best practice and evidence based efforts to improve physical fitness and reduce CVD in firefighters. Incorporating principles of Community Based Participatory Research (CBPR) may be an efficacious orientation for guiding firefighter community involvem ent in the application of IM in the development, delivery, and evaluation of health programming since studies show worksite health promotion efforts involving the target community in the research process has been successful for increasing physical activity ( Israel, et al., 2005 ; Pazoki & Nabipour, 2007 ) CBPR is recognized as a critical orie ntation in efforts to effectively reduce health disparities in underserved communities ( Pazoki & Nabipour, 2007 ) involves community members, organizational representatives, and researcher s in all ( Wallerstein & Duran, 2006 ) Both CBPR and IM are founded upon the ecological model, wherein as it has evolved in the behavioral sciences and in public health, the ecological model focuses on influential factors at the individual, interpersonal, community, environmental, and policy levels of health. Incorporating CBPR and IM in promoting health of firefighters may be an effective strategy due to the unique characteristics inherent in the firefighter profession. Compared to most other professions, firefighter have distinct personality traits, rely more heavily upon the social dynamics of team work, have unique cultural norms, are present in the work environments for longer periods of time (24 hour shifts), and are governed by paramilitary style institutional policies of job performance, conduct, and behavior ( Elliot, et al., 2007 ) Therefo re, the orientation of CBPR and Intervention Mapping may have practical applications for guiding health promotion efforts to reduce

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132 CVD in firefighters. Theory based health promotion efforts are more likely to succeed when delivered through a well designed health planning model ( Green & Kreuter, 2005 ) Decades o f research examining the determinants of PA behaviors and the effectiveness of interventions promoting PA provides meaningful insight towards identifying the appropriate theoretical understandings and health planning models needed for increasing physical f itness via PA in firefighters ( Biddle & Nigg, 2000 ; Farag, et al., 2010 ; Greaves, et al., 2011 ; Kahn, et al., 2002 ; Sallis, et al., 2000 ) Social Cognitive Theory (SCT) and Intervention Mapping (IM), have both emer ged as an efficacious health theory and planning model respectively for increasing PA ( Antikainen & Ellis, 2011 ; Booth, et al., 2000 ; Foster, et al., 2005 ; Kok, et al., 2004 ; Michie, et al., 2009 ) IM is a protocol specifically designed for systematically applying theoretical strategies when developing, implementing, and evaluating health promotion programs ( Bartholomew, et al., 2006 ) .The synergistic influence of individual characteristics, interpersona l interactions, and environment factors (reciprocal determinism), as postulated by SCT ( Bandura, 1986 ) is well matched for translation into the work structure found in the firefighter profession ( Elli ot, et al., 2007 ; Murphy, et al., 2002 ) Reciprocal determinism can be applied since firefighters are characterized by unique individual traits inherent to their profession, rely heavily upon the social dynamics of team work, are present in the work environments for longer periods of time (24 hour shifts), and are governed by paramilitary style institutional policies for job performance, conduct, and behavior ( Elliot, et al., 2007 ; Melius, 2001 ) The purpose of our study is to evaluate the ability of a peer me ntor based worksite health promotion program based on SCT and IM to significantly increase

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133 cardiorespiratory fitness (VO 2 max), reduce body fat percentage, and increase musculoskeletal fitness in high risk firefighters. Our working hypothesis is that unheal thy firefighters who participate in a three month Peer Fitness Intervention (PFI) will significantly increase VO 2 max, maintain body fat percentage (no significant increase in body fat composition), and increase musculoskeletal fitness compared to firefigh ters in controlled conditions. Methods Participants Firefighters from a North Central Florida Fire department (n=144), completed a battery of physical fitness health measures to identify firefighters considered to be at an increased risk for CVD. The crit eria for classifying firefighters as high risk for CVD was based on possessing both a VO 2 max score below 40 ml/kg/min and possessing a percentage of body fat considered to be overweight (>23% male, >33% female) ( Gallagher et al., 2000 ) These VO2max valu es and body fat percentages were used as the discriminating risk factors because they are strongly associated with CVD risk ( The Emerging Risk Factors Collaboration, 2011 ) Firefighters identified as high risk (n=24) were then recruited into the study and randomly assigned into ei ther treatment (full intervention) or comparison (environmental and policy change only) groups. Both groups (and the entire fire department) were exposed to various environmental and policy level changes targeting increased physical activity levels. The tr eatment group was exposed to the full ecological intervention which included an individualized three month intervention in addition to the changes that occurred department wide. The individual intervention was delivered by peer mentor firefighters and base d on Social Cognitive Theory. Institutional Review Board approval was obtained in all 24 of the

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134 firefighters who voluntarily consented to participating in the study prior to baseline testing and the intervention. Health Measures Each participant complete d baseline, three month, and one year follow ups on a variety of physical fitness health measures including: sub maximal aerobic capacity (VO 2 max) assessment, body fat percentage, BMI, hand grip strength, arm and leg strength, push ups, abdominal static pl ank, and a flexibility (sit and reach) test. These health measures were selected from the physical fitness standards created from the firefighter National Wellness & Fitness Initiative that was set forth by the International Association of Firefighters and the Fire Chiefs Association ( International Association of Firefighters, 2009 ) These health measures were obtained by a trained team of firefighters who were all able participate in baseline and post testing data collections to ensure consistency in measurements. Aerobic capacity (also known as VO2max), is the maximal volume of oxygen that can be utilize d during maximal or exhaustive exercise, and is measured in milliliters of oxygen used in one minute per kilogram of body weight (ml/min/kg) ( Powers & Dodd, 2003 ) Predicted aerobic capacity was measured using the firefighter Wellness Fitness Initiative (WFI) sub maximal graded exercise treadmill test and is widely used among fi re departments across the nation to assess VO2max. In the WFI sub maximal test, participants complete a standard protocol of increasing intensity over time until the participant reaches 85% of their age predicted maximum heart rate [(220 age) x 0.85]. The amount of time taken to reach 85% of their age predicted maximum heart rate during the WFI sub maximal test (test time), and the BMI of participants is inserted into an equation [56.981 + (1.242 x test time) (0.805 x BMI)], to predict their true VO 2 max. This sub maximal test was developed by a fire department

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135 physician in Arizona, and has been shown to be significantly and moderately correlated (r=0.6348, p value =0.05) in predicting trueVO2max by the authors of this present study ( Delisle et al., 2010 ) A variety of physical fitness measurements were performed in accordance with WFI fitness assessment proto cols ( International Association of Firefighters, 2009 ) Body fat percentage was estimated using a thr ee point skin fold body composition. In males, triceps, subscapular, and pectoral measurements were used, and females were measured at the triceps, abdominal, and superiliac sites. Hand grip, arm, and leg strength was measured as a static contraction and w as measured with a dynamometer reported in kilograms. Push ups were measured by the total number of continuous biomechanically sound repetitions completed without stopping. The abdominal static plank was measured by timing the total number of seconds a par ticipant was able to maintain a biomechanically sound body position. Flexibility was measured by using a sit and reach box test, and reported in inches. Peer Mentor Intervention Using a CBPR approach, researchers teamed with peer mentor firefighters to de velop, deliver, and evaluate the intervention. Peer mentor firefighters were selected based on criteria that included: firefighters who possessed a strong working knowledge and commitment to physical fitness, those who were well respected among their peers and those who have a sincere desire to enhance the physical fitness of their co workers. Ten fire fighters meeting these criteria were identified and recruited, with a total of eight agreeing to participate in peer mentor training and programming. Once f ormally recruited, the eight firefighters received 40 hours of training based on the

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136 theory based curriculum developed by the investigators of this study. The American Co uncil on Exercise training program focused on teaching education based information regarding the components and principles of physical fitness. The peer mentors received additional training provided by the researchers of this investigation on behavioral ch ange strategies consistent with Social Cognitive Theory and included the modeling of health behaviors (observational learning), goal setting (expectancies), skill building techniques (behavioral capability), motivational reinforcement, and methods for buil ding confidence (self efficacy). Training from researchers also included strategies based on the ecological model the peer mentors used to create positive social normative attitudes towards aerobic fitness, ideas for modifying environmental factors for pro moting physical activity, and methods to advocate for policies in promoting PA in the treatment group. One on one meetings between the peer mentors and participants in the treatment group were administered weekly during the intervention and consisted of cu stom tailored exercise plans based on individualized fitness levels, preferences for PA, role modeling experiences, and motivational reinforcements to be physically active. Weekly personal goals were developed for each participant with supportive activitie s designed to be build skills, be interactive, enjoyable, and consistent with principles of adult education; emphasizing relevance and active learning in the application of the new skills. These skill building activities involved the use of several key the oretical constructs belying SCT including role modeling (observational learning), addressing belief structures (expectations, expectancies), enhancing skills related to PA behavior (behavioral capability), and confidence building experiences ( self efficacy ). The weekly

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137 meeting were supplemented by following up with participants over the phone throughout the week to monitor progress on their individual goals. Statistical Analysis T o examine the ability of a peer mentor based worksite health promotion progra m to significantly improve physical fitness in high risk firefighters, we tested mean differences of cardiorespiratory fitness (VO 2 max), body fat percentage, and musculoskeletal fitness between and within treatment and control groups. All analyses were per formed using SAS version 9.2 (SAS Institute Inc., Cary, NC, USA). Distributions were first tested for normality and then a repeated measures Analysis of Variance test (ANOVA), was conducted to examine mean differences between treatment and contr ol groups. Multivariate Analysi s of Variance was conducted to examine within group changes since the assumption of a common spherical covariance matrix had not been met When within group significance was detected from MANOCA testing multiple paired sample t tests w ere performed at baseline, 3 month and one year follow up. Formative evaluation was conducted to assess the quality of intervention development and training; process evaluations were conducted to assess the quality of implementation of the intervention inc luding the fidelity and adherence of participation by peer mentors and participants in the treatment group. Results All 144 firefighters in the department completed baseline physical fitness assessments to identify high risk firefighters and 24 were identi fied as high risk. Table 4 1 describes sample and department wide baseline health measures and shows that the sample recruited for the study were older, had a lower average VO 2 max, and higher body fat composition than the department as a whole. Baseline eq uivalence was tested

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138 prior to intervention with independent samples t tests on all health factors assessed between the treatment and control groups and revealed both groups were similar (not significantly different at the p=0.05 level), and is described in Table 4 2. Table 4 3 describes the sample means for each of the assessments of the intervention group and the control group both at baseline and 3 month post test. Statistical analyses using the independent and paired samples t tests (Table 4 4) examined if health measures significantly changed from baseline to post testing both within and between groups. Sub maximal aerobic capacity significantly increased from a baseline of 37.38 mlO 2 /min/kg to 39.98 mlO 2 /min/kg at 3 month post testing for the intervent ion group ( p < 0.001). The control group significantly increased body fat percentages of 28.71% at baseline to 29.53% at post testing (p =0 .044), while the intervention group maintained body fat percentages from 30.48% at baseline to 30.20% at post testing ( p =0.384 ). No significant increases or decreases were detected in any of the musculoskeletal health measures in either treatment or control group from baseline to post testing. Assessment of the long term impacts of the intervention was conducted through collection and analysis of 12 month follow up (9 months post intervention) aerobic capacity data in both groups (Table 4 5). Paired sample t tests evaluated whether the improvements in VO 2 max were sustained in the intervention group (Table 4 6) and indepe ndent samples t tests analyzed if the long term changes seen differed significantly betwe en the two groups (Table 4 7). The results of the tests showed that the intervention group not only sustained, but showed a non significant trend of continued improvem ent of mean VO 2 max from the end of the study (3 month follow up)

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139 until the 12 month follow up (mean c hange 0.7383, p value 0.1045). The intervention group showed a n overall strong trend of significant improvement from baseline to 1 year follow up (mean cha nge of 2.998, p value 0.0004) significant at the p<0.005 level. The comparison group showed a small improvement in mean VO 2 max from 3 month post intervention to follow up (0.310 mean change, p value 0.4126), yet from baseline to 1 year follow up, they sti ll showed a non significant overall decline (mean change 0.4146, p value 0.3926). Discussion The hypothesis that high risk firefighters participating in a three month peer mentor intervention will significantly improve aerobic capacity and musculoskeleta l health measures, while decreasing body fat percentage compared to those in control conditions was partially met. The intervention group significantly increased VO 2 max while the control group did not. The control group significantly increased percentage o f body fat while the intervention group did not. Further, the intervention group showed a trend of continued improvement in VO 2 max after the conclusion of the peer mentor portion of the program. Aside from a significant decrease in right hand grip strength from baseline to post testing in the intervention group, no other significant increase or decrease was observed for any of the musculoskeletal health measures for either the treatment or control group. Therefore our results indicate that firefighters expo sed to a peer mentor based intervention can increase aerobic capacity and maintain body fat percentages over firefighters who do not receive such an intervention. Further, it shows that impacts on VO 2 max are sustained at least 9 months after the conclusion of the intervention.

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140 The significant increase in aerobic capacity of firefighters that was sustained post intervention in the treatment group is encouraging since there is a strong relationship between VO2max and risk of CVD. A low VO2max is a primary r isk factor for premature mortality and morbidity due to CVD ( Haskell, et al., 2007 ; P. N. Peterson, et al., 20 08 ; Sui, et al., 2006 ) events (Peterson et al. 2008). A longitudinal cohort design study controlling for BMI, found individuals who coul d not achieve 85% predicted VO 2 max had significantly more fatal and nonfatal myocardial i nfarctions, unstable angina, and hypertension than those who could achieve 85% predicted VO2max ( Peterson, et al., 2008 ; Sui, et al., 2006 ; Sui, et al., 2007 ) A recent prospective study of over 25,000 asymptomatic men demonstrat ed that low VO2max exercise tests are highly predictive of subsequent cardiac death, and the association increases for each additional CVD risk factor present ( Sui, et al., 2006 ; Sui, et al., 2007 ) In fact research shows VO2max may be one of the most important health measures related to CVD and is now believed to be an even stronger predictor of fatal and nonfatal CVD in firefighters than obesity ( Harvey, et al., 2008 ; Leiba, et al., 2011 ; Poston, et al., 2011 ; Rhea, et al., 2004 ; Smith, et al., 2001 ) The strong relationship between low aerobic capacity and CVD is concerning since studies find 25% of firefighters fail to achieve the cu rrent minimum firefighter standard VO2max for of 42.0 ml/kg/min ( Harvey, et al., 2008 ; International Association of Firefighters, 2009 ; Mier & Gibson, 2004 ) Our sample represents these firefighters since b oth the intervention and control group s had average VO2ma x values well below the current minimum standard (37.4 and 38.9 mlO 2 /min/kg respectively). The intervention group significantly increased VO2max by 3.0 mlO 2 /min/kg from a baseline

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141 of 37.4 mlO 2 /min/kg to a one year follow up of a 40.4 mlO 2 /min/kg. This increase has important real world implications for efforts to address substandard VO2max in firefighters since the intervention group began 4.5 mlO 2 /min/kg below the minimum standard of 42.0 mlO 2 /min/kg at baseline and was only 1.5 mlO 2 /min/kg below this standard at one year fo llow up. In comparison, the control group began at 3.1 mlO 2 /min/kg below the minimum firefighter standard at baseline and 3.5 mlO 2 /min/kg below this standard at one year follow up. Therefore our findings of a significant increase in aerobic capacity due to intervention are clinically meaningful for firefighters with low cardiorespiratory fitness since all participants in our sample had a VO 2 max well below 42.0 ml/kg/min. As with the sample we examined, a substandard VO 2 max is significantly associated with the presence of other CVD risk factors in firefighters such as obesity, thus increasing the likelihood of developing CVD ( Donovan, et al., 2009 ; Poston, et al., 2011 ) The control group demonstrated they were compounding this dual risk for CVD since they significantly increase percentage of body fat and did not improve their VO 2 max. Improvements in CVD risk factors were seen in the inte rvention group as they maintained their body fat percentage while significantly increasing their VO 2 max. No significant changes in body fat percentages in the treatment group indicates it was maintained during the intervention, which is often deemed a succ ess in weight management research since body fat percentages tend to increase over time with age and without intervention ( Lee, et al., 1999 ) Although insignificant, body fat percentages were declining in the treatment group and further research is needed to better understand the long term trajectories of this change.

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142 Positive non significant changes in the other physical fitness measures in the intervention group, such as leg strength, static plank, and sit and reach flexibility tests are also important to note. Increasing performance in auxiliary exercises and overall physical fitness can also reduce the risk of CVD even ts ( Harvey, et al., 2008 ) Although significance was not detected in aforem entioned health measures, the trajec tories were trending towards improved health and could potentially lead to a significant change over time. The large decrease seen in grip strength in follow up testing of the intervention group may be related to a mecha nical malfunction of the hand dynamometer that was us ed on the day of post testing. This device was later discovered to not be properly calibrated and had to be sent off to the manufacturer for repair. The results of this pilot study demonstrate efficacy of worksite health interventions using peer based efforts for firefighter populations to improve critical health indicators related to CVD such as increasing aerobic capacity and maintaining body fat percentages. The sustainability of the changes after the program concluded were supported as continued improvements were seen in the intervention group at one year follow up. These findings have important implications due to the limited success of worksite health interventions for improving physical fitness ind icators via promoting physical activity ( Dishman, et al., 1998 ) and the overall lack of successful CVD interventions in the firefighter population. Many researchers believe the ineffectiveness of worksite health promotion efforts to improve physical fitness is largely due to a lack of effective planning and theory driven approaches to intervention design ( Conn, Hafdahl, Cooper, Brown, & Lusk, 2009 ; Dishman, et al., 1998 ) The strength of the current study is that it involved the systematic planning from the use of a Community Based

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143 Participatory Research ( CBPR ), approach that incorporated Intervention Mapp ing Both researchers and firefighters agreed involving firefighters in the planning, implementation, and evaluation of the intervention was a key component in obtaining a 100% participation rate from all 144 firefighters in baseline assessments, from high risk firefighters to participate in either treatment or control conditions, and from the firefighters serving as peer mentors. Another strength was the application of several Social Cognitive Theory constructs such as role modeling of physical activity be haviors through vicarious learning, developing behavioral capability via skill building activities, and increasing self efficacy to perform physical activity. The use of CBPR helped to identify SCT as the health behavior theory to use during the planning p hase, and was integral in implementing peer mentor efforts to promote physical activity in high risk firefighters, and was critical for empowering firefighters to take the lead on evaluating physical fitness since their professional skill set predisposes t hem to be competent in measuring health indicators. Involvement of firefighters in the participatory process of development, delivery, and evaluation of the program may have contributed to the high rate of program fidelity, dose delivered and received of t he physical intervention as reported from the formative and process program evaluations. Results of this study should be interpreted in lieu of several limitations. First, the findings of the study may be limited due to the small sample size of both tre atment and control groups A small sample size limited the ability to conduct a within group ANOVA since the assumption of a common spherical covariance matrix had not been met. A larger sample size would increase the likelihood of meeting the assumption o f a common spherical covariance matrix, and would also allow for more statistically robust

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144 analysis such as regression modeling to plot the slopes of change over time. Additional studies of firefighters involving larger samples drawn from urban, rural, and suburban settings, along with more diverse demographic populations, would improve external validity. Although the sample was small, it did over represent female firefighters since 20.8% of the participants in our sample were female, compared to the 13 % o f female sample size in our study may account for the lack of statistical significance detected for musculoskeletal fitness outcomes due to reduction of statistical power. The fact statistical significance was detected z in a small sample demonstrates a peer mentor intervention can produce a large effect size exists for increasing aerobic capacity, and that a large effect size may exist for increasing body fat percentage in high risk firefighters when no intervention is present Future research is also needed to identify efficacious strategies for increasing musculoskeletal fitness, such as incorporating intervention components targeting significant health influences in fire fighters that are outside of the work environment The firefighting profession requires a high level of physical fitness to perform on duty tasks and to protect against CVD. Few fire departments have health programs that promote physical activity, require on duty physical activity or to maintain minimum standards for physical fitness. Additionally, little research exists regarding the effectiveness of health programs to promote physical activity and fitness in firefighters. Our pilot study demonstrated effi cacy for peer mentor based efforts to increase aerobic capacity and maintain body fat percentage in firefighters. In addition to the favorable impact physical activity has on the task specific and physical fitness risk factors related

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145 to CVD events in fire fighters, it is a low cost, feasible, safe therapy with minimal risk of adverse side effects ( Elliot, et al., 2007 ; MacKinnon, et al., 2010 ) Therefore, future research should examine the effectiveness to promote physical fitness in firefighters via peer driven phy sical activity worksite health promotion efforts in larger samples of diverse firefighters,

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146 Table 4 1. Baseline d escriptive m easures for d epartment wide, i ntervention group and comparison g roup Variable Department wide mean ( 95%CI ) Co mparison g roup m ean ( 95% CI) Intervention g roup m ean (95% CI) N 144 12 12 Age 38.9 (37.3, 40.5) 45.8 (39.2, 52.4) 44.3 (39.5, 49.1) Gender (% male) 8 7 1 83. 9 75. 8 VO2max 43.2 (42.6, 43.9) 38.0 (36.7, 39.3) 37.4 (35.5, 39.3) Body f at % 22.2 (21.1, 23.3) 28.9 (25.9, 32.0 ) 30.3 (27.5, 33.0) Table 4 2. Baseline equivalence of control and intervention g roup Variable (mean/ std dev) Co mparison group Intervention group Paired samples T test p value Age (yrs) 45.73 44.33 0.688 VO2 max (ml O2/kg/min) 38.9 (2.68) 3 7.4 (2.99) 0.179 Body f at (%) 28.7 (3.7) 30.5 (4.47) 0.329 L eft h and m ax (kg) 52.5 (7.52) 57.7 (13.41) 0.216 Leg m ax (kg) 139.4 (21.37) 132.7 (34.32) 0.537 Arm m ax (kg) 41.2 (10.01) 42.6 (15.48) 0.782 Push u ps (reps) 23.5 (8.55) 23.7 (7.18) 0.949 Sta tic p lank (min) 1.53 (0.83) 1.83 (0.97) 0.390 Sit and r each (in) 15.4 (3. 54 ) 16.2 (3.00) 0.434

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147 Table 4 3. Baseline and 3 m onth p ost test Variable Mean (std dev) Co m parison Group (n=12) Intervention Group (n=12) Pre test Post test Pre test Post test VO 2 max (ml O2/kg/min) 38.9 (2.68) 38.1 (1.63) 37.4 (2.99) 39.6 (2.78) R igh t hand m ax (kg) 52.9 (8.43) 54.8 (6.34) 60.9 (11.42) 56.8 (11.32) L e ft hand m ax (kg) 52.5 (7.52) 52.8 (6.55) 57.7 (13.41) 53.6 (13.73) Leg m ax (kg) 139.4 (21.37) 142. 3 (19.48) 132.7 (34.32) 133.2( 25.96) Arm m ax (kg) 41.2 (10.01) 45.0 (13.09) 42.6 (15.48) 41.4 (9.97) Push u ps (reps) 23.5 (8.55) 21.3 (8.68) 23.7 (7.18) 23.7 (5.19) Static p lank (min) 1.53 (0.83) 1.42 (0.67) 1.83 (0.97) 1.58 (0.52) Sit and r each (in) 1 5.4 (3.54) 15.1 (2.54) 16.2 (3.00) 16.5 (2.46) Body f at (%) 28.7 (3.7) 29.5 (3.71) 30.5 (4.47) 30.2 (4.46)

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148 Table 4 4 Baseline to 3 month f ollow up c hanges in o utcome measures: Paired s amples t test Intervention g roup C o mparison g roup Variables Mean (Std dev) P value Mean (Std dev) P value VO2m ax* 2.259 (1.646) 0.0006* 0.145 (0.501) 0.3838 Body f at 0.330 (0.808) 0.2289 0.675 (0.778) 0.0438 L eft hand s trength 4.008 (7.513) 0.0864 0.000 (1.4142) 1.000 R ight hand s trength* 4.083 (6.244) 0.0447 0.400 (1.837) 0.5086 Leg s trength 0.550 (17.026) 0.9129 2.770 (4.785) 0.1004 Arm s trength 1.208 (11.787) 0.7292 2.280 (10.465) 0.5082 Push u ps 0.083 (9.249) 0.9757 0.700 (2.111) 0.3217 Static p lank 0.250 (0.933) 0.3730 0.101 (0.404) 0.4698 Fle xibility 0.270 (1.539) 0.5545 0.281 (0.784) 0.3442 Table 4 5. Baseline, 3 month, and 1 year f ollow up m ean a erobic c apacity v alues VO2max (mlO2/kg/min) Timeline Interv e ntion group n=12 Mean (std dev) Comparison group n=12 Mean (std dev) Baseline 37.4 (2.99) 38.9 (2.68) 3 month 39.6 (2.78) 38.1 (1.63) 1 year follow up 40.4 (2.20) 38.5 (3.74)

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149 Table 4 6. Long term c hanges in VO2max in i ntervention and c omparison g roups Intervention g roup Comparison g roup T ime period measured Mean change (std dev) p value Mean change (std dev) p value B aseline to 3 month 3 month to 1 yr follow up 2.259 (1.646 ) 0.738 (1.45) 0.0006* 0.1045 0.145 (0.501) 1.104 (2.17) 0.3838 0.1926 Baseline to 1 yr follow up* 2.998 (2.10) 0.0004* 0.514 (2.09) 0.3926 Table 4 7. Between group d ifferences in 1 y ea r m ean c hanges in VO2max (Intervention vs. Comparison Groups) Mean (std dev) p value Baseline to 1 yr follow up 3.512 (2.10) 0.0004

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150 Figure 4 1. Measured Aerobic Capacity in Intervention and Comparison Groups Note: A VO2max of 42.0 ml/Kg/min i s minimum safe standard for firefighters

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151 CHAPTER 5 SUMMARY, CONCLUSIONS RECOMMENDATIONS, A ND IMPLICATIONS Summary The present research focused on car diovascular disease prevention in firefighters. Specifically, this research primarily focused on three integrated studies. The purposes for each of the studies were: 1) to describe the methods used to engage firefighters in the participatory processes of p lanning, implementing, and evaluating a CVD prevention program utilizing Intervention Mapping (IM). 2) t o evaluate the validity of the current WFI sub maximal VO 2 protocol used to predict the true VO 2 max of firefighters. 3) t o examine the use of a peer dri ven firefighter worksite health promotion intervention on increasing physical activity, improving cardiorespiratory fitness, body composition, and other for requirements. The study in C hapter 2 examined the participatory processes a Community Academic Partnership (CAP) used to integrate the principles of Community Based Participatory Research (CBPR) with the methods of Intervention Mapping (IM) to develop, deliver, and evaluate a worksite health promotion program targeting cardiovascular disease (CVD) risk factors in firefighters. Two fire departments, representatives from a local public health department, and three health oriented university academic departments comprised the C AP. The results of the study found facilitating partnerships in all phases of the research process building upon the strengths of the community, and capacity building and co learning were the most frequently utilized CBPR principles integrated into the ste ps of IM. Key elements of the health program developed from the process of integrating principles of CBPR with IM

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152 included: establishing department wide annual physical fitness and CVD screenings; training of firefighters to serve as Peer Fitness Trainers (PFT); validation of instrumentation evaluating cardiorespiratory fitness of firefighters; identification of firefighters at highest risk of CVD; PFT driven development and delivery of individually tailored fitness interventions; improved access to workout equipment; and policy changes to mandate on duty physical activity. The CAP ultimately created and delivered a one year CVD prevention program resulting in an 8% increase in cardiorespiratory fitness (p=0.001) in high risk firefighters, while capitalizing on the community capacity, thus, requiring minimal financial resources. The study in C hapter 3 examined the validity of the current sub maximal VO 2 test used to measure aerobic capacity of firefighters to predict their true VO 2 max ascertained from the Br uce VO 2 max Protocol. Thirty healthy firefighters completed both the sub maximal and Bruce protocols. The estimated sample mean values for the sub maximal and true VO 2 max were similar; 44.583.91 mlO 2 /kg/min and 45.687.22 mlO 2 /kg/min respectively. Although the means are similar, the ranges of values and standard deviations differed between the predicted and true VO2max values (min max: 35.4 to 50.9vs.28.6 to 58.4 mlO 2 /kg/min, and standard deviation of 3.91 vs7.22 respectively). This suggests the predictio n formula compresses VO 2 max values into a more narrow range than what is true. Additionally, the sub maximal test under predicted the true VO 2 max in 72.4% of firefighters, and over predicted in 27.6% of the firefighters tested. The estimated and true VO 2 ma x values were moderately corre lated (r = 0.6348, p = 0.005). True VO 2 max values were also significantly and moderately correlated with

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153 one minute recovery heart rate (r=0.537, p=0.0038), percentage of body fat (r=0.5178, p=0.0080), and resting blood pressu re (r= 0.541, p value=0.0035). Chapter 4 describes a study in which firefighters from a North Florida Fire department (n=144) completed a battery of physical fitness and CVD risk factor assessments to identify firefighters at increased risk for CVD. Fir efighters identified as high risk (n=24) based on these measures (primarily a VO 2 max score < 40 and higher body fat composition) were recruited into the study and randomly assigned into either treatment or control groups. The intervention group was exposed to a one year Peer Fitness Intervention (PFI) based on Social Cognitive Theory, which was delivered by firefighters trained to be peer fitness mentors. Both intervention and control groups completed baseline and one year post testing across a broad range of health outcome measures. The baseline equivalence of the two groups was tested with a paired samples t test on all factors assessed and indicated there were no significant differences between the two groups at baseline. Statistical analyses using the in dependent and paired samples t tests showed which key health measures significantly changed from baseline to post testing both within and between groups. Sub maximal aerobic capacity significantly increased from a baseline of 37.38 ml/min/kg to 39.98 ml/mi n/kg at post testing for the intervention group ( p < 0.001). The control group significantly increased body fat percentages of 28.71% at baseline to 29.53% at post testing (p = 0.044), while the intervention group maintained body fat percentages from 30.48% at baseline to 30.20% at post testing ( p =0.384 ). Though not statistically significant, the intervention group also showed a decrease in body fat percentage, arm

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154 strength, pushups, and hand grip strength, and an increase in leg strength, abdominal static p lank, and sit and reach. Conclusion These investigations represent the first efforts to examine the participatory process of engaging firefighter and academic partners in the planning, implementation, and evaluation of CVD health program for firefighters; to validate the current sub maximal cardiorespiratory fitness test used for assessing aerobic fitness of firefighters; and to assess the effects of a peer driven intervention for improving physical fitness of high risk firefighters. Findings from this rese arch suggest integrating principles of CBPR into health planning models such as IM, is an efficacious process for involving firefighters and academics in all phases of the research process, designing key elements for a health program relevant to the cultur e of firefighters, for building community capacity of firefighters to deliver and assess a health program, and to ensure long term commitments of firefighters and academic partners for the sustainability of health programming. The inherent culture of firef ighters may predispose this population towards the participatory process involved in health promotion. These cultural characteristics include a work structure emphasizing team work, paramilitary style policies governing behavior and conduct, norms emphasiz ing the importance of a high level of physical fitness, and expertise for assessing health indicators. Additionally, the overlapping core concepts between IM and CBPR may account for the success of fostering and sustaining a CAP with firefighters for the p urposes of health promotion. Both IM and CBPR are guided by similar conceptual frameworks s concerning health promotion efforts including: i nvolving the participation of the target community in all phases of research utilizing the e cological approach towa rds understanding and

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155 intervening upon health outcomes, d eveloping capacity via capitalizing on assets within the community, and in using an i terative process in program development, implementation and evaluation. The congruency of these concepts complemen ted the efforts of integrating the systematic and well structured methods of IM with the orientation of CBPR. With regards to the cardiorespiratory validation study, the sample means for the sub maximal prediction and Bruce VO 2 maxprotocols were similar, t he sub maximal VO 2 treadmill test underestimated the true VO 2 max in the majority of healthy firefighters, and overestimated the VO 2 ma xin less healthy firefighters. This finding is concerning given the main purpose for using this test is to identify firefig hters at risk for on duty CVD events. A test that over predicts the true VO 2 max of unfit firefighters will not identify those at greatest risk for on duty CVD, nor provide the opportunity to help intervene to improve the cardiorespiratory fitness of these high risk firefighters. The sub maximal test was shown to be moderately correlated (r = 0.6348, p = 0.005), in its ability to accurately predict the true VO 2 max of firefighters. A moderate correlation may be considered low for a physiologically based predi ction test, and is potentially unacceptable for clinical applications. Additionally the ranges of values differed between the predicted and trueVO 2 max values (min max: 35.4 to 50.9 vs. 28.6 to 58.4 mlO 2 /kg/min, and standard deviation of 3.91 vs. 7.22 res pectively). This suggests that the prediction formula for the sub maximal test compresses the VO 2 max values into a more narrow range than what is true. A potential danger in this is that a firefighter with low true VO 2 max is likely to have a higher predict ed VO 2 max, thus limiting the tests ability to identify a high risk firefighter. Resting Heart Rate, resting blood pressure, and

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156 three point skin fold body composition measures were determined to be significant and moderately correlated to true VO 2 max. Ther efore, assessing recovery heart rate, blood pressure, and body composition in conjunction with the sub maximal test may improve the precision of this test, and perhaps eliminate the issues this current assessment has in over or under estimating the aerobi c fitness levels of firefighters. The hypothesis that high risk firefighters participating in a one year PFT intervention will significantly improve aerobic capacity and muscular conditioning, while decreasing body fat percentage compared to those in cont rol conditions was partially met. The intervention group significantly increased aerobic capacity, did not significantly increase muscular conditioning assessments or significantly reduce body fat percentage. Although significance was not detected these me asures, the trajectories for body fat percentages were decreasing and several muscular conditioning assessments were increasing. These non significant findings are important because these measures were trending towards improved health and could potentially lead to a decreased risk of CVD related events in firefighters. The trajectory of decreasing body fat percentage is particularly encouraging since the body fat percentages significantly increased in the control group. No significant changes suggest that b ody fat percentages were maintained during the intervention, which is often deemed a success in weight management research since body fat percentages tend to increase with age and without intervention ( The Emerging Risk Factors Collaboration, 2011 ) Therefore our results indicate that firefighters exposed to a peer mentor based intervention can increase aerobic capacity and maintain body fat percentages over firefighters who do not receive such an intervention. Increased aerobic capacity and maintenance of body

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157 fat percentage of fi refighters in the treatment group is very encouraging given these health indicator are shown to have significant and strong relationship with the likelihood of developing CVD in firefighters ( Yoo & Franke, 2009 ) Recommendations for Future Research The findings from this study suggest the following actions: The use of community based orientations, health program planning models, and social behavioral theories in the development, implementation, and evaluation of CVD prevention programs for firefighter populations To investigate the use of peer driven interventions to promote cardiovascular health and physical fitness in firefighter populations with a larger sample size then was investigated in the present study (n=24). Additional studies of firefighters involving larger samples drawn from urban, rural, and suburban settings, along with more diverse demographic populations, would improve external validi ty. To conduct longitudinal studies examining the effectiveness of interventions on promoting cardiovascular health of firefighters for a longer period of time than was examined in the present investigation. To investigate the how social culture normati ve beliefs of firefighters influence the practice of health behaviors related to cardiovascular disease. Anecdotally, our study revealed firefighters assigned gender roles to the practice of physical activity and nutrition behaviors often leading them to c hoose strength building over aerobic activities and a heavy animal based diet over a plant based diet. Understanding how a members of male dominated profession, such as firefighting, assign and act upon perceived gender roles of different health behaviors, may lead to social marketing efforts to alter these perceptions and encourage the practice of CVD protective health behaviors.

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158 To examine the effectiveness of promoting healthy nutrition behaviors for the prevention of CVD in firefighters. To examine the effects of interventions targeting social networks of firefighters outside of the fire department, such as their family members, for promoting physical activity and healthy nutrition in firefighters. To validate the WFI sub maximal VO 2 test with a greater sample size of firefighters, especially for female firefighters, and in firefighters of varying fitness levels, particularly unfit firefighters. To investigate whether the precision of the current WFI sub maximal VO 2 test to predict trueVO 2 max can be impro ved buy incorporating health indicators significantly correlated to true VO 2 max (such as blood pressure, recovery heart rate, and percentage body fat), into the WFI sub maximal prediction formula. Implications Despite the need for future research, this st udy provides important implications for the prevention of CVD events in firefighters. First, this study is the first of its kind to demonstrate efficacy in applying the principles of Community Based Participatory Research towards the process of fostering a nd guiding a Community Academic Partnership for addressing CVD in firefighters. This finding implies the unique dynamics of the firefighter profession make it readily accessible to the orientation and application of CBPR, thus CBPR is likely to be a useful approach for future health promotion efforts in firefighters. Second, this is the first study to validate the current WFI sub maximal VO 2 test used in firefighters in its ability to accurately predict cardiorespiratory fitness of individual firefighters. Though this test is useful for measuring mean aerobic capacity levels of groups of firefighters, our findings suggest this test is not sufficient in its

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159 precision to accurately measure the true aerobic capacity of firefighters. This is likely due to high v ariability in true maximum heart rate, body composition, and metabolic characteristics between individuals. However, for the purposes of tracking changes of VO 2 max within individuals, the test appears to be reliable due to individual factors that impact th e accuracy of the results are unlikely to vary within the individual. The WFI sub maximal VO 2 test was shown to either under predict or over predict the true VO 2 max by greater than 10% in a majority of firefighters tested The implication for this finding is that high risk firefighters may not be identified, and that a new test is needed in order to accurately identify firefighters who are at risk for on duty CVD events. Third, results of this study provide support for efficacy of worksite health interventi ons using peer based efforts for firefighter populations to improve critical health indicators related to CVD such as aerobic capacity and body composition, in high risk firefighters. These findings have important implications due to limited success of wor ksite health interventions for improving physical fitness indicators via promoting physical activity ( Dishman, et al., 1998 ) In addition to the favorable impact PA has on the task specific and biological risk factors for CVD in firefighters, these intervention efforts are likely to be translatable and disseminated to other firefighter communities as these efforts to in crease PA is a low cost, feasible, and a safe therapy with minimal adverse side effects ( Elliot, et al., 2007 ; MacKinnon, et al., 2010 ) Therefore the implications of this study suggest firefighters, academic partners, and public health officials should: use commun ity based orientations, health program planning models, and social behavioral theories in the development, implementation, and evaluation of CVD prevention programs for firefighter populations; utilize a more

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160 accurate cardiorespiratory fitness assessment f or assessing aerobic capacity of firefighters than what is currently being used; and to use peer mentoring strategies such as role modeling of physical activity behaviors through vicarious learning, developing behavioral capability via skill building acti vities, and developing self efficacy to perform aerobic physical activity for improve cardiorespiratory fitness and maintenance of body composition in firefighters who are high risk for CVD.

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161 APPENDIX A PARTICIPANT INFORMATION Validation of VO 2 Max Data Fo rms Name of Fitness Assessor: _________________________ Date________________ Informed Consent Form Signed? ____YES ____NO General Information Subject ID Number:_______________________ Have you exercised today? YES NO (If yes, how much exercise?) Have you had any caffeine (coffee, soda) today? YES NO Are you on any medications that a ffect your heart rate? YES NO Age______ Gender_______ Height (in)_______________ Weight (lbs)________________ Resting Heart Rate___________ (bpm) Resting Blood Pressure______/_______ BODY COMPOSITION: BIA Scale Bioelectrical Impedance (BIA scale) Weight (lbs)__________________ Body Fat% __________________ Body Muscle%___________ __ __ BMI________________________ Waist Hip Ratio Waist (upper abdominal): ___________(in) Hip (gluteal): _________________(in) Waist/Hip ratio: ____________________ Body Fat %: 3 Point Skin Folds Trial #1 Trial #2 Trial #3 Average Men: Triceps _________ __________ __________ __________ Chest __________ __________ __________ __________ Subscapular __________ __________ __________ __________ Sum of Skinfolds __________ Women: Triceps __________ __________ __________ ________ __ Abdomen __________ __________ __________ __________ Suprailiac __________ __________ __________ __________ Sum of Skinfolds __________

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162 APPENDIX B WFI SUBMAXIMAL AEROBIC CAPACITY ASSESSMENT CARDIOVASCULAR FITNESS: WFI 85% Sub maximal Trea dmill Test Resting Heart Rate _____________ bpm Resting Blood Pressure _____/______ Age Predicted Max Heart Rate (220 age) _______ bpm 85% HR max ______ bpm WFI 85% Sub maximal Treadmill Test Protocol Stage Time (mi n) Speed (mph) Incline Heart Rate Bl ood Press RPE Rest 1 0:00 3:00 3.0 0 % 2 3:01 4:00 4.5 0 % 3 4:01 5:00 4.5 2 % 4 5:01 6:00 5.0 2 % 5 6:01 7:00 5.0 4 % 6 7:01 8:00 5.5 4 % 7 8:01 9:00 5.5 6 % 8 9:01 10:00 6.0 6 % 9 10:01 11 :00 6.0 8 % 10 11:01 12:00 6.5 8 % 11 12:01 13:00 6.5 10 % 12 13:01 14:00 7.0 10 % 13 14:01 15:00 7.0 12% 14 15:01 16:00 8.0 12% 15 16:01 17:00 8.0 14% Recovery 1 0:00 1:00 Recovery 2 1:01 2:00 Recov ery 3 2:01 3:00 Recovery 4 3:01 4:00 Total Time (min: sec) _____:______ TT Decimal (min) _________________ Predicted VO2max = 56.981 + (1.242 x TT) (0.085 x BMI) = ___________ml/kg/min Predicted VO2 MAX _____________ ml/kg/min

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163 APPENDI X C BRUCE VO 2 MAX ASSESSMENT CARDIOVASCULAR FITNESS: Bruce VO2 Max Protocol Ht. ______(in) ______(cm) Wt. ______(lbs.) ______(kg) BMI________(kg/m2) Medications_________________________________________________________ Clinical History__________________ ___________________________________ RESTING DATA Supine BP = _______/______mmHg Sitting/Standing BP =_____/_____mmHg Supine HR = __________b/min Sitting/Standing HR =___________b/min Resting EKG Interpretation_________________________________________ TABL E 2a: BRUCE PROTOCOL Stage Time (min) Speed (mph) Grade (%) Heart Rate (bpm) Blood Press (mmHg) RPE Comments (symptoms, EKG, etc.) 1* 3:00 1.7 10 / 2 3:00 2.5 12 / 3 3:00 3.4 14 / 4 3:00 4.2 16 / 5 3:00 5.0 18 / 6 3:00 5.5 20 / 7 3:00 6.0 22 / VO2 Max: _______L/min _______ ___ml/ kg/min RER (RQ): __________ ___ Recovery Data Time (min) Speed (mph) Grade (%) Heart Rate (bpm) Blood Pressure (mmHg) RPE (6 20) Comments (symptoms, EKG, standing or supine, etc.) / / / /

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164 Reason Terminating the Test: 2 criteria required: VO2 Max Plateau Maximal Heart Rate RER> 1.15 RPE of 20 1 criterion required: Fatigue Dyspnea Leg Fatigue Chest Pain Other:________________________ __

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165 APPENDIX D BRUCE PROTOCOL CHECKLIST Before the subject arrives, the following must be done o Check to see if the treadmill is working o Check to see if there EKG display is working o Make sure there are enough electrodes o Cables are not tangled o Check to see i f the computer program is running o Warm up the machine for 30 minutes o Assemble Clean mouthpiece o Mouth pieces should be cleaned with a 1:10 bleach to water solution o Parts Saliva tube Snorkel like mouth piece 2 one way valves White air tube Clear air tube Nos e clip Head gear o Assemble spirometer tubing to computer o Adjust placement of the computer and the EKG screens so subject will not be distracted by them. They should be in plain view of the test administrator. o Place RPE scale in plain sight of subject and re searcher Calibrating the Machine: o Open the Program True Max o o Set the room temperature, barometric pressure, relative humidity, etc. o Follow prompt to Turn the Oxygen tank counter clockwise 90 degrees o Press ok o Let the machine calibrate o Press ok o o Turn the oxygen tank back to where it needs to go o Check the gas calibration parameters to make sure they are correct. o Pull up Flow meter calibration o Press Sample Baselin e o Hook up the 3 Liter Syringe to the spirometer tube o Steadily pump the 3 L syringe 9 times. o 3 strokes to remove old air o then 5 more

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166 o As long as the % error is under two percent you are ok o o Enter VO2 Metabo lic Testing Participant Prep: o Provide participant with parking pass and escort them to lab o First obtain PAR Q o Then obtain informed consent and give the participant a copy o Obtain LTQ questionnaire o Use self reported age o Use self reported gender o Measure hei ght on the wall. DO NOT USE SELF REPORTED HEIGHT o Use BIA scale to measure weight, BMI, % body fat o Measure Resting Heart Rate and Blood Pressure o Blood Pressure with a diastolic pressure of above 100 will not be qualified to participate o Continuously communic ate to the patient what you are doing as you are doing it o Decide on a non verbal stop signal for subject to stop the test o Place electrodes on chest o Place electrodes with lead hook facing in such a way that the leads will face towards the ground o 4 arm and l eg o 6 ventricle V1 + V2 are placed in the 4 th intercostal space between the ribs V4 is placed directly under the nipple/pectoral muscle V3 is placed in between V2 and V4 V6 is placed straight down from the arm pit V5 is placed in between V4 and V6 in a curv ed line o Shave chest if needed o Hook electrodes to leads Keep leads as organized as possible. Avoid tangling the leads Attach leads to the top of the treadmill so they do not hang or tug on the electrodes o Put shirt back on o Have subject put in mouth piece o In struct the subject to breath normally to check if the valves have been inserted correctly o Instruct the subject to hold the mouth piece in a comfortable position o Tighten the cap in a position that comfortably secures the mouthpiece in place

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167 o Have subject sta nd on either side of the tread mill belt o Assemble spirometer tubing to mouth piece output valve and to the computer o Adjust for comfort Computer and Participant Prep o Enter subject information and press ok o Height, weight, name, age, gender o Enter Maximal Tes t o Treadmill Test Administration: o o Have spotter stand behind the subject throughout the test to catch them if they trip o Continuously communicate with the subject throughout the test what is being done as it is bein g done o o Ask RPE at each stage 2 minutes and 2:45 into the stage. o First two minutes are a warm up at 2 or 3 miles an hour. No grade. o Start the Tread mill at 1.7 mph at 10% grade o Stages are 3 minutes each as follows: Stage 1 = 1.7 mph at 10% Grade Stage 2 = 2.5 mph at 12% Grade Stage 3 = 3.4 mph at 14% Grade Stage 4 = 4.2 mph at 16% Grade Stage 5 = 5.0 mph at 18% Grade Stage 6 = 5.5 mph at 20% Grade Stage 7 = 6.0 mph at 22% Grade Stage 8 = 6 .5 mph at 24% Grade Stage 9 = 7.0 mph at 26% Grade o Adequately move through the stages at the proper times o Inform the subject at the end of each stage that there will be a change o Tell them what speed and grade they will increase to o Ask them if they are fit to continue o Let the subject cool down at 2mph and 0% grade o During recovery continue to measure post exercise HR, BP, RPE for about 5 minutes o Continue to monitor the subject

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168 Indications to Stop the Test o Systolic Blood Pressure drops 20 mmHg or fails to ri se with increasing workloads o Systolic Blood Pressure > 260 mmHg o Diastolic Blood Pressure >115 mmHg o 3+ on the Angina scale o >2 mm ST depression or signs of ST elevation related to ischemia o Lightheadedness, ataxia, pallor, nausea, cyanosis o Failure of testing or EKG monitoring equipment o SUBJECT REQUESTS TO STOP Criteria for obtaining a VO2 Max: o Plateau in VO2 (<150 ml/min) with an increase in work rate o Heart rate of +/ 10% of age predicted max and/or failure of HR to increase with increasing work rate o RER > or = 1.15 o RPE > or = to 20 o The 1st Criteria is the definitive test o If #1 is not met, but at least 2 of the other 3 are, the test can be considered valid. o If the criteria are not met, the highest VO2 value is recorded as "VO2 peak" Clean Up o Turn Off all equ i pment o Wash mouth pieces in 1:10 bleach to water solution for 10 minutes o Hang mouth pieces to dry. Equations for Estimating VO2 max without a computer program o For Men VO2 max = 14.8 (1.379 x T) + (0.451 x T) (0.012 x T) o For Women VO2 max = 4.38 x T 3.9 o T = Total time on the treadmill measured as a fraction of a minute ( i.e. : A test time of 9 minutes 30 seconds would be written as T=9.5).

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169 APPENDIX E PHYSICAL ACTIVITY RECALL SURVEY Firefighter ID: ___________ Date:_____________________ Go odwin Leisure Time Exercise Questionnaire Regular Exercise is any planned physical activity (e.g., aerobic activities such as jogging, bicycling, swimming, rowing, or muscular conditioning exercises such as lifting weights.) performed to increase physical fitness. Such activity should be performed. Question: Do you exercise 5 times per week for 30 60 minutes per session ? Circle one: 1) Yes, I have been for MORE than 6 months 2) Yes, I have been for LESS than 6 months 3) No, but I intend to in the next 30 da ys 4) No, but I intend to in the next 6 months 5) No, and I do NOT intend to in the next 6 months During a typical 7 day period (weekly average), how many days on the average and for how long do you do the following kinds of exercises (write the average num ber days and average time spent in minutes). Strenuous Aerobic Exercise (Hearts Beats Rapidly )(e.g. running, jogging, soccer, basketball, swimming, long distance bicycling, roller skating ) Number of days Per Week: ____________ Average time in min utes exercising per day ______________ Moderate Aerobic Exercise (Heart beats steadily Not Exhausting) (e.g. fast walking, baseball, tennis, easy bicycling, volleyball, badminton, easy swimming, popular and folk dancing) Number of days Per Week: ________ ____ Average time in minutes exercising per day ______________ Mild Exercise (Minimal Effort) (e.g. easy walking, meditative yoga, archery, fishing from river bank, bowling, horseshoes, golf,) Number of days Per Week: ____________ Average time in minutes exercising per day Muscular conditioning exercises (to the point where your heart beats rapidly) (e.g. Weight lifting, functional training, calisthenics, power yoga) Number of days Per Week: ____________ Average time spent exercising per day ____________

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183 BIOGRAPHICAL SKETCH To ny was born in 1969 and raised in Ormond Beach Florida. H e graduated from Father Lopez Hig h School in 1987, graduated with his undergraduate degree in exercise and sport s cience s from the University of Florida in 1992, and earned his Master of Exercise an d Sport Sciences degree in December 1995 with major in exercise and sport sciences Prior to entering the doctoral program in h ealth e ducation and b ehavior, Tony gained twelve years of professional experience working with children, youth, and young adults in various settings including public schools, Department of Child and Family Services, and as a manger for a non profit agency. His professional experience includes seven years of K 12 instruction in public schools (physical education, health education, and special education), over four years of counseling wayward youth and adolescents remanded into state custody, and five years of experience as a program manager for an in novativ e nonprofit agency serving high risk adolescents and young adults. Tony returned to UF in 2005 and earned his Master of Science degree in May 2008 with major in health education and behavior On returning, he gained six year s of experience teaching health based courses to undergraduate and graduate students including Medical Terminology, Personal and Family Health, and Foundations and Principles of Health Promotion. Tony was awarded the 2011 UF Graduate Student Teacher of the Year. As a doctoral stu dent, he became the research director for a community academic partnership examining the health effects of outreach programs on young adults with an intellectual disability. This program involve d over 100 university based volunteers in delivering comprehen sive peer mentor activities to promote physical, cognitive, and social health based outcomes for students with intellectual

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184 disabilities. Tony has three scientific manuscripts accepted in peer reviewed journals, eleven national conference poster presentati ons, and one oral presentation at the American Public Health Association 2011 conference.