This study used a scoping review methodology to analyze 35 intervention studies on Korean firefighters published in Korean and international academic journals since 2010. The characteristics of the identified intervention studies and three key factors regarding future research directions are discussed.
The number of intervention studies targeting Korean firefighters has increased consistently. In Korea, there has been a growing awareness of the importance of firefighter welfare, as evidenced by the enactment in 2012 of the Framework Act on Health, Safety and Welfare of Firefighting Officials, the Human Rights Status Survey of Korean Firefighters in 2015 [51], the conversion of local firefighters to national civil servants in 2020, and the establishment of a national fire hospital (scheduled for completion by 2025). Moreover, the occurrence of major disasters, such as the Gyeongju and Pohang earthquakes in 2016 and the Pyeongtaek logistics warehouse fire in 2022, in which firefighters were urgently required and tragically lost their lives, has served to heighten awareness regarding the health issues facing firefighters.
The analysis suggests that the intervention studies on Korean firefighters, along with the quantitative research, should consider firefighter characteristics in the research design process. Among the studies included in this review, recent publications have made efforts to reflect firefighter characteristics by conducting focus group interviews with current firefighters to identify on-site needs and by selecting the most comfortable spaces and timeframes for participants to conduct research. Moving forward, intervention research that reflects firefighters’ job characteristics and organizational climate is needed.
Recommendations for future research
This study summarized three key factors for improving the quality of intervention research: design and content, tailoring and ethics, and characteristics and demands of the field.
Design and content
Although the number of intervention studies on firefighters has been increasing steadily, there has been a notable imbalance in terms of the research topics, study designs, outcome variables, and forms of intervention delivery. A mental health survey conducted by the Fire Administration in 2021 indicated that PTSD was reported by 5.7%, depressive symptoms by 4.4%, sleep problems by 22.8%, and problematic drinking by 22.7% [52]. The rate of PTSD of 5.7% is significantly higher than the prevalence of PTSD in the general population, reaching approximately tenfold [51]. This review indicated that Korean firefighters are at an elevated risk of mental health issues, with numerous intervention studies being conducted to address this issue. However, the principles of mental health promotion programs outlined by the World Health Organization and International Labor Organization indicate that they should be comprehensive, in conjunction with other health promotion programs, in order to be effective. Firefighters who have experienced PTSD have been found to exhibit significantly higher rates of cardiovascular, respiratory, musculoskeletal, and nervous system symptoms than those who have not [53]. Since mental health problems often manifest as biological symptoms, such as insomnia or pain, maintaining biological health is crucial for mental health management [54]. Most of the studies included in this review focus on psychological and social interventions to address mental health issues. In future research, it is essential to design intervention studies that employ a multidimensional approach to address mental health issues among firefighters in Korea and integrate them with other health promotion programs.
In addition to mental health issues, Korean firefighters face various health problems. According to the Human Rights Status Survey of Korean Firefighters [51], 48% of the respondents reported experiencing pain or discomfort related to musculoskeletal issues; 5.4%, asthma attacks; 29.1%, skin symptoms; and 22.7%, hearing loss. Particularly, there was evidence of unmet medical demands for pain, rehabilitation, and burns [55]. Moreover, the International Agency for Research on Cancer has designated firefighting as a Group 1 carcinogen because of the high risk of cancer associated with occupational exposure among firefighters. Consequently, firefighters incur significantly higher costs than general public officials for mental health, cardiovascular, and musculoskeletal disorders. They spend 6.1 times more on mood disorders, 12.4 times more on hypertension, and 8.4 times more on lumbar disc issues [56], leading to a substantial economic burden due to medical expenses. Firefighters’ health issues can have socioeconomic implications beyond individual concerns [18]. Therefore, intervention studies addressing various health issues are essential for promoting the mental and physical health of firefighters, reducing medical expenses, and ensuring societal safety.
Therefore, it is crucial to conduct high-quality intervention studies using optimal experimental designs. Randomized controlled trials (RCTs) are the gold standard for evidence-based research, in which participants are randomly assigned to experimental and control groups. This methodology ensures that the two groups are homogeneous except for the intervention, which allows for causal inference. However, RCTs require significant resources, such as manpower and costs, which are often unavailable in research settings. Therefore, it is essential to provide research funding for conducting RCTs. Studies that receive formal research funding can allocate more resources based on economic benefits [57, 58]. This enables the provision of high-quality interventions, which ultimately enhances the quality of research. Among the 35 studies included in this review, only two (5.7%) employed an RCT design. In both articles, an explicit statement was made that the research had received funding. However, in 19 studies (54.3%), research funding support was not clearly disclosed, making it difficult to discuss the research design and funding. Therefore, future studies should be transparent regarding research funding. Moreover, increased research funding is essential to actively implement RCT methodology in future research, thereby boosting the quality of intervention studies on firefighters.
The most prevalent format of intervention delivery among the included studies was the group-based face-to-face format (n = 19, 54.3%), with only four studies (11.4%) conducting follow-up observations. Given that firefighters are repeatedly exposed to traumatic incidents, repeated training over multiple sessions is necessary to enhance psychological resilience and proficiency in required skills [59]. Moreover, studies with extended follow-up observation periods are necessary to investigate the long-term effects of these interventions. However, considering the irregular response times and shiftwork characteristics of the firefighters, repeated training over multiple sessions may interfere with their work and rest. Furthermore, as organizations are sensitive to the stigma associated with health issues, it has been difficult to recruit candidates willing to participate publicly in group programs [21]. Moreover, the use of self-report questionnaires in group-based face-to-face intervention programs may have resulted in participants underreporting their health issues, which could have compromised the reliability of the results. Regarding the outcome variables, 26 studies (74.3%) employed self-report questionnaires. It is well established that self-report questionnaires may introduce bias in the results, as respondents may present themselves as healthier than they actually are, and individuals with higher social desirability tend to report less stress than they actually experience [60, 61]. Consequently, to provide evidence of intervention effectiveness that is not limited to a single dimension and to present objective results, it is necessary to use objective measurement tools along with self-report questionnaires. However, most of the studies included in this review reported interventions at the group level. In such cases, completing self-report questionnaires as a group may facilitate research progress, as it would be challenging to measure objective indicators for each participant individually. Among the studies included, only 4 out of 21 studies (19%) that provided group interventions and 5 out of 6 studies (83.3%) that provided individual interventions used objective evaluation tools. The group-level intervention studies employed relatively simple evaluation indicators, such as saliva cortisol analysis or tests following checklists for educational evaluation. Individual intervention studies utilized relatively complex evaluation indicators, including blood tests, physical and biochemical indicator evaluations, and bio-signal analysis. Consequently, it is essential to develop a range of intervention formats tailored to the specific research context and intervention type rather than relying on a single uniform group-based face-to-face approach. Furthermore, research designs that incorporate both self-report questionnaires and objective evaluation indicators are necessary. Studies involving long-term follow-up observations to assess the long-term effects of interventions and case management of research participants are needed as well.
Tailoring and ethics
Firefighters are exposed to different risks depending on their assigned tasks [62–64], working periods [65], and gender [66], and the resulting health issues vary, making individual health issues heterogeneous within the group. Moreover, firefighting is among the occupations with the highest prevalence of mental health issues requiring case management [52]. Scholars have opined that suicide prevention strategies should prioritize the early identification of high-risk groups and the enhancement of emotional coping skills [28], underscoring the necessity for tailored interventions over uniform ones. However, a limitation of existing studies is the lack of targeting specific firefighter groups in the selection criteria of the included studies. Only seven studies (20%) classified high-risk groups. Furthermore, 12 studies (34.3%) conducted interventions tailored to individual characteristics rather than implementing a common intervention for all participants. This is related to the fact that only 10 (28.6%) of the included 35 studies specified the inclusion and exclusion criteria in their design, indicating that most studies targeted all firefighters and lacked customization during the research process. Although intervention studies targeting all firefighters are necessary, there is a need for interventions that consider individual characteristics. Furthermore, it is essential to provide evidence-based interventions by referencing past studies, pilot studies, or expert consensus when designing the research and selecting appropriate participants.
Topics that are stigmatizing and socially sensitive, such as identifying high-risk groups for diseases and investigating experiences of discrimination, must prioritize the protection of participants’ privacy and confidentiality. In particular, stigma poses a significant issue in male-dominated occupations such as firefighters [67]. A nationwide study conducted among firefighters revealed that the majority of firefighters at risk of developing PTSD did not seek treatment, with 33.8% citing concerns about potential stigma [55]. Furthermore, a survey on firefighters’ human rights status [51] found that 40% of female firefighters had experienced workplace discrimination in the past year, with 57% attributing it to gender. However, 98% of female firefighters who experienced sexual harassment did not report this to the authorities. This indicates that firefighters, considering that the nature of their profession emphasizes trustworthiness and robustness, have significant concerns about being stigmatized or perceived as vulnerable [8]. Therefore, when addressing topics such as identification of high-risk groups for diseases or discrimination experiences among firefighters, it is essential to instill trust in research participants regarding personal information protection and research ethics. Among the studies included in this review, only 15 (42.9%) mentioned obtaining IRB approval, while 26 (74.3%) mentioned obtaining participant consent. This represents a more favorable outcome in terms of research ethics compared to the trend analysis of health-related intervention studies for children conducted at regional child centers [68], where only two out of 109 studies (1.8%) obtained IRB approval and 41 studies (37.6%) obtained participant consent. However, since the implementation of the Basic Act on Bioethics in Korea in 2013, all research involving human subjects must undergo review and approval by the appropriate IRB before proceeding. Therefore, when designing studies on high-risk group identification and discrimination, as well as intervention studies involving humans, it is essential that researchers consider the protection of participants’ privacy and confidentiality and the ethical conduct of the research in advance, with these plans being established and approved by the IRB.
When conducting intervention studies, both adherence to approved IRB protocols and documenting the implementation of these protocols in the article are essential. Among the five studies that identification of high-risk groups and obtained IRB approvals, three explicitly addressed participant protection methods (Table 2). Despite adherence to IRB-approved participant protection and research ethics, one study [7] reported difficulties in participants sharing their experiences due to concerns about the potential negative consequences in their careers and fear of appearing vulnerable during one-on-one counseling sessions. Employees experiencing mental health issues often hesitate to disclose their problems because of concerns about stigma in the workplace [69]. This underscores the significance of addressing social skills, such as the attitudes of intervention providers and the establishment of trust with participants, in addition to IRB approval, in intervention studies. Furthermore, sensitive research designs that consider appropriate intervention methods, timing, and location are essential to accommodate participants' needs. In group-based, face-to-face programs, it is of paramount importance to ensure that populations that are high-risk or discriminated against are not singled out. If the identification of high-risk groups or discrimination experiences is intended, all stages of the program should target the entire participant group, with individual feedback on diagnostic results and research progress. In instances where this is not a viable option, alternative methodologies such as online or virtual reality-based interventions, in conjunction with anonymization techniques employing pseudonyms or other means, can safeguard the privacy of participants. Furthermore, if the study design identifies high-risk groups or those who have experienced discrimination as the sole participants, it may be necessary to consider alternative modalities of intervention delivery. For instance, the intervention could be delivered individually or virtually, rather than in a group-based face-to-face program. Moreover, to mitigate negative perceptions and biases towards mental health treatment among firefighters, it is necessary to implement programs that target all firefighters.
Characteristics and demands of the field
Despite the numerous intervention studies targeting Korean firefighters, these studies have failed to adequately reflect the irregular duty hours and demands of fieldwork, including irregular emergency response times and shift work. Among the 35 studies included in this review, various opinions regarding suitable intervention locations and timings were identified through post-intervention reflections. The limitations of studies that conducted interventions within fire departments during the workday were described as follows: ‘The intervention was not easily implemented in an environment where we had to wait for an emergency response. The sirens and emergency response affected the implementation of and participation in the intervention [70].’, ‘We were unable to see a significant difference in outcome 'variables because we had to leave in the middle of the intervention due to unexpected work events [71].’, and ‘It was not uncommon to have to return to the site without meeting the participants due to emergency response [21].’ Overall, interventions conducted at fire stations during working hours encountered challenges in separating firefighter duties from intervention provisions, making it difficult to assess intervention effectiveness. Therefore, future interventions should aim to increase intervention focus by separating intervention time and location from work responsibilities. The limitations of studies that conducted interventions outside of the fire station during off-duty hours were described as follows: ‘Conducting the intervention after work may have the physical and psychological burden on participants [72].’, and ‘Using personal time, such as holidays, may have reduced participation and effectiveness [7].’ Due to the nature of shift work among firefighters, providing interventions during personal time after long shifts may burden the participants and reduce intervention effectiveness. Moreover, given the varying shift schedules of firefighters, it may be challenging to gather all participants at designated times. Overall, future efforts should focus on improving working conditions such as ensuring sufficient staffing for shift work or providing interventions directly at fire stations during working hours. Some studies have attempted to address these issues, including the implementation of shorter intervention sessions to accommodate emergency response constraints [46], scheduling of interventions during low average emergency response times, provision of separate spaces within fire stations [70], overcoming the limitations of past studies, and conducting research outside the workplace [42]. However, these measures did not provide fundamental solutions. Consequently, future research should investigate the intervention timing and locations that maximize the effectiveness of interventions targeting firefighters.
The preceding recommendations are reflections based on researchers' perspectives through the review of the intervention studies. There is a paucity of research analyzing the opinions of firefighters—the research participants—through qualitative studies to identify solutions. Among the 35 studies selected for this review, six employed qualitative methods, including five mixed-method studies (14.3%) and one qualitative study (2.9%). One study [19] designed an intervention based on the demands and perceptions related to the intervention, identified through focus group interviews with 12 firefighters. The findings suggested the need for flexibility to accommodate individual and organizational characteristics of firefighters, practical content provided by firefighting experts, avoidance of outcome orientation, and inclusion of positive content rather than focusing solely on negative aspects. This study used a flexible research design that allowed participants to select the most comfortable time and space outside their working hours. Additionally, to avoid stigma, the study conducted anonymous online counseling rather than a somewhat uncomfortable psychological program. In this manner, the intervention was tailored to the needs of the participants and involved experts in firefighting psychology, demonstrating a deep understanding of firefighting.
Among the 35 studies, 4 (11.4%) involved researchers directly providing the intervention, while 15 (42.9%) involved other professionals, such as specialized therapists. The majority of these professionals were not firefighting experts but were experts in the specific intervention. Future research should focus on meeting firefighters' demands by having intervention experts provide interventions, while including firefighting experts in the research design and intervention provision process to meet their unmet needs. Furthermore, discussions on suitable intervention locations and timings have been revealed to be researcher-centric in post-intervention reflections. Consequently, future research should focus on the participants during the research design phase. Moreover, given the current dissatisfaction resulting from one-sided program operations that do not meet participants' demands and lack diversity [22], there is a need for research to ascertain the demands of the field regarding the types of intervention studies required.
Strengths and limitations
This is the first comprehensive scoping review of intervention studies targeting Korean firefighters. It provides an integrated analysis of existing intervention studies from various perspectives based on firefighters’ job characteristics and organizational culture. The significance of this study lies in the recommendations for subsequent intervention studies. Alongside this scoping review, the research team will conduct qualitative [29] and survey research targeting Korean firefighters to identify unmet healthcare needs. Additionally, clinical data based on a memorandum of understanding between the Seoul Korean Medicine Association and Seoul Metropolitan Fire and Disaster Headquarters will be leveraged through retrospective chart reviews to undertake a series of research tasks aimed at promoting the health of Korean firefighters. The results of this study will serve as foundational data for future intervention studies targeting Korean firefighters.
However, this study had some limitations. First, as the study focused on publications in Korean and international journals since 2010, there may have been studies published before 2010 that were excluded, including theses, government documents, policy reports, and conference proceedings. Second, as only intervention studies targeting Korean firefighters were included, the findings may not apply to other countries and regions.