Our data reveal a higher prevalence of exposure than is found in similar studies in the developed world. Compared with a study of US fire personnel (who achieved a median on the CCI of 8.5; range 0 to 534
) our sample had far greater exposure. Similarly, in a study of Swedish ambulance drivers, 61.6% reported ever experiencing a critical incident,13
whereas over 88% of our sample had experienced a critical incident in the past 2 months alone. A feature that appeared unique to our context is the multiple stressors arising from dealing with fires in informal settlements.
For all but the sea rescue service, our data reveal higher rates of general psychopathology than found by studies of Scottish14
ambulance personnel (caseness rates of 32% and 22% respectively). In addition, it is clear from our findings that symptoms of anxiety, depression, and PTSD, and experience of both physical and psychological aggression increase, without levelling off, as exposure to critical incidents increases, although rate of increase may slow as exposure increases.
Although these findings are true for all the services, certain groups are more at risk for experiencing aggression. Members of the defence force are more likely to be assaulted, as are younger members of ambulance services. In addition, women across all the services are more at risk for being the victims of psychological aggression.
Our finding of higher rates of anxiety and depression, however, is in line with the typical gender expression of distress; in the general population, women are more likely than men to develop anxiety and depression, while men tend to demonstrate distress more frequently via aggression or substance abuse.16
As our data did not directly measure externalising disorders in men, our finding that rates of anxiety and depression are higher in women may thus indicate only that this is the form women's response to critical incident exposure takes. Services should be alert to the possibility that there is a gender dependent response to critical incident exposure, rather than assuming that women are more vulnerable.
Our finding that there is no association between critical incident exposure and alcohol use is similar to other studies from a variety of developed world contexts.17,18
Despite this, rates of problem drinking in this population are high and services should be alert to this possibility among their staff.
The responses to the open ended questions revealed that death notification and dealing with family members of injured victims are also particular stressors that emergency services personnel face. Although other literature identifies death notification as stressful,19
emergency services personnel seldom receive particular training in this area.20
The responses to our open ended questions shed further light on other areas that may be difficult for emergency services personnel. As has been found in other contexts,5
problems within and between organisations were found to be stressful for the emergency services. It is very likely that these organisational stressors interact with the characteristics of critical incidents and may move them from being merely “incidents” to being “critical incidents”. For instance, where there are no clear co‐operation agreements between services, there is likely to be confusion when members of several services respond to an incident and this confusion may lead to greater loss of life.
This study does have several limitations. Firstly, as this is a cross sectional study, we can only note associations between critical incidents and mental health and behavioural problems. While (for instance) exposure to critical incidents leads to depression, depressed personnel may be more likely to make mistakes on the job, and hence experience more incidents that become “critical”. Secondly, we relied on retrospective data for the critical incidents, and on self report data throughout. Furthermore, the cross sectional nature of the study does not make it possible to determine whether the “caseness' registered here is simply an immediate response to critical incident exposure that will be remedied over time, or whether this reflects a more enduring, persistent harm. Prospective studies that follow staff over long periods of time will be more able to detect the duration and direction of effects. Similarly, the GHQ was developed for a primary care population,7
which one would expect to have lower rates of “caseness”. It may be that in this particular population new norms need to be established.