IMHA-Research self-rated health risk factors at sea - multicenter project/The Blue Public Health Surveillance and Intervention Program

Introduction
About ten years ago, the ILO introduced the SOLVE training package: Integrating health promotion into workplace OSH policies in 2012. Health promotion in the workplace had until then been neglegted by the ILO. The material covers the management of health promotion at the workplace to deal with nine topics: stress and economic stress, violence, tobacco and smoke-free workplaces, alcohol and drugs, nutrition, physical activity, healthy sleep and HIV/AIDS. The package includes a participant's workbook, a trainer’s guide, lesson plans and a CD-ROM with presentations and background material.A specific package has not been introduced for seafarers and fishermen, but is highly relevant and the program will be research based. WP17 Solve ilo

The seafaring employees face more difficult working conditions and living conditions in the sea than the employees working on land. Their health is affected by the environment in which they live, often coupled with long working hours that contribute to eating more carbohydrate food and less physical activity in a working environment with high demands and long working hours. stress, This proposal seeks to improve the seafarers’ well-being on board that attracts the youngest seafarers to choose and to stay in the job.

The idea of the program is that all employees in the maritime industry take their personal responsibility for the prevention of health risks. The health professionals take their specific responsibility in the maritime industry ´in coordination and as a part of the WHO global health prevention system. One of the main tasks for the health professionals is to make a continued overall adequate and updated assessment and priorities of what should be done where and how. This is based on a permanent monitoring of the health risks and the health conditions in all the different segments of the industry. The monitoring uses various tools, among other things, using self-reported data, clinical data, health and mortality registry data. The planning and the prioritizing of a comprehensive preventive program needs training, relevant high competency among the professionals and willing to coordinate the tasks with the other partners. The responsibility to implement the needed preventive actions lies on the shoulders of all professionals in the maritime industry. Therefore, a continuing education in the maritime health system is extremely important.

Methods
The theories on empowerment, life-long- and problem oriented learning with inclusion of all stakeholders form the theoretical background. A joint action among the unions, ship owners, maritime authorities and a network of universities´ research centers and maritime health departments studies include [23]. The seafaring employees face more difficult working conditions and living conditions in the sea than the employees working on land. Their health is affected by the environment in which they live, often coupled with long working hours that contribute to eating more carbohydrate food and less physical activity in a working environment with high demands and long working hours loneliness and stress. This proposal seeks to improve the seafarers’ well-being on board that attracts the youngest seafarers to choose and to stay in the job by including the whole maritime industry. The task is to create responsibility among all stakeholders to help to create a comprehensive occupational- and public health program at sea that includes the whole maritime industry. Methods: The theories on empowerment, life-long- and problem oriented learning with inclusion of all stakeholders form the theoretical background. A joint action among the unions, ship owners, maritime authorities and a network of universities´ research centers and maritime health departments studies include [23] We should establish an international comprehensive public- and occupational health promotion program for the whole shipping industry. The objective to improve the quality of life at sea by starting in the maritime schools. Theories on empowerment, life-long- and problem oriented learning with inclusion of all stakeholders form the theoretical background. A joint action among the unions, and a network of universities´ research centers and maritime health departments studies include:


 * 1) Repeated surveys (and new scientific studies) on knowledge, attitudes and occupational health risk factors
 * 2) Monitoring of clinical variables and exposures on board (physical, mental, chemical, ergonomic..)
 * 3) Based on that, health and risk reduction education in the whole industry
 * 4) Monitoring of health and working health risk indicators, diet and exercise
 * 5) Based on that to point out polices with the specific needs for structural changes in the workplace (ILO SOLVE)
 * 6) Implementation of best practices for health promotion in the companies and on board and follow up of the effects
 * 7) Empowerment of the youngest,training,  problem oriented learning to promote quality of life at sea
 * 8) Political and international guidelines to reduce risk factors that will not else be changed due to economic factors.

SEAFARERS
Studies on the health profile of the seafarers show worse health in almost all indicators as compared with those of the general population Standardized hospitalization records show higher rates of cardiovascular diseases, cancers, and injuries than other occupations. The seafarers face more difficult working conditions at sea than the employees working on shore. Among other difficulties, they report struggling with long periods away from their family, circular working hours, limited communication capabilities with their own social networks and limited choices for healthy food and physical exercise. Their health is affected by the environment where they live and work, but also by the ports, they visit during their trips. These occupational factors can have an impact on both their individual health behaviour (e.g. smoking, alcohol consumption, unhealthy diet) and their exposure to occupational risks (psychosocial, biological, chemical, and physical factors) depending on ship type ,. Organisational aspects, such as unreliable contracts and long working hours, contribute to stress and depression (See the Blue Public Health program). Depression and suicides have devastating consequences not only for seafarers’ families, but also for fellow employees and the industry.

FISHERMEN
For fishermen a similar disease pattern is seen. The conditions of work in the fisheries sector are arduous with high incidence rate-ratio of non-fatal and fatal accidents compared to other jobs. Logically, the prevention activities mainly focused on accident prevention with little attention to the emerging chronic diseases, like diabetes and cardiovascular diseases·

Several studies have shown that fishermen have a higher morbidity and mortality from cardiovascular disease, diabetes, cancer than other occupations. The results are consistent with the causal explanations in studies about obesity and related health conditions also called the metabolic syndrome. The main risk factors include alcohol, fatty food consumption, smoking and lack of physical exercise. And the negative health effects are causally related the mentioned risk which in turn relate to the specific working conditions and culture in small-scale fishing. This needs to be taken into consideration in the prevention programs.

According to the Luxembourg Declaration of June 2005, health promotion at the workplace is "the combined effect of employers, employees and society's efforts". From the international side, the WHO announced in February 2007 that health promotion is an integral part of the work environment work. The International Labor Organization (ILO) included health promotion as part of the work environment some 10 years ago. It is obvious to apply the land-based initiatives, for example, such as the Danish KRAM (Food, Smoking, Alchohol and Physical movement) model to the fishing industry, based on the special conditions of the fishing industry.

Aims
The overall goal is to introduce the general multifactorial causal model for health promotion needs to be adapted in a concerted action to the specific working conditions at sea.

Challenges
The main challenges are to get the Maritime Authorities, the shipowners, the unions and their members to be "project owners". Thus to take their responsibility and participate actively in the project. The Danish unions have expressed their clear interest but the Maritime Authority and the ship owners organisation have so far been reluctant to support the project. The reluctance or the lack of understanding is clearly expressed in the latest statement from the Maritime Authority in Denmark: Maritime Strategy Team 2016

Conclusions
International collaboration in research and development of health promotion programs in fishing and seafaring seems to be highly needed. These industries cover relatively small commercial areas in the countries, so its important to have international collaboration. A good start could be to bring together the initiatives that are currently taking place in some countries, for mutual inspiration between many other countries to establish a program. However there are other most important stakeholders whose decisions can have great impact on the seafarers and the fishers´ health and safety. The knowledge, attitude and practical decisions should be studied because they are the ones who can improve or deteriorate the working and living environment for the workers at sea. An important challenge is to get the maritime authorities and the shipowners to participate actively in this process

The study populations
The study populations include all the stakeholders, those who work at sea and those who stay at home. : the shipping companies, the maritime authorities, the maritime students, the seafarers, the employees in the shipping companies, the maritime medical doctors, the Radio Medical doctors, the maritime school teachers and comparison groups onshore with power to change the working and living conditions. There is a gab to develop the more precise mapping of the stakeholders in shipping and seafaring. There is a gab of research to classify the different types of fishery, artisanal and large scale trawlers, equal for the diffent types of shipping companies. without that any effort to change the conditions that are so closely governed by the economic interests. We see the shipowners, the ministriers and the maritime authorities lack of knowledge in Public Health There is a gab of research to identify the knowledge, attitudes among the empoyees in these powerful institutions  As long this continues ... no changes probably All these should be studies about their, knowledge and needs for education and training.


 * Fishermen and seafarers
 * Ministries of resources and research
 * International organisations like FAO and ILO
 * Shipping companies
 * Maritime Authorities,
 * Schools

Theory- and evidence-based health promotion
The program is based on the WHO theories on empowerment and the inclusion of all stakeholders in a public health prevention strategy applied for the shipping industry. The WHO’s comprehensive Public health action plan WHO 2013-2020 Action Plan calls for a change in the attitudes that perpetuate stigma and discrimination that have isolated people. The program calls for an expansion of services in order to promote greater efficiency in the use of resources. This program for the shipping industry will focus on the youngest seafarers´ knowledge, competencies and needs for training and for quality life on board in order to attract them to shipping and to hold on them in the future. Evidence-based medicine has developed over the last half century and was formally defined by Sacket et al. in 1996. , Later the evidence-based health promotion was developed to include planning interventions based on solid scientific knowledge and planning for public health programs including Public health promotion to be applied here. The intention is to produce the needed scientific research for promotion of quality of life and prevention of social isolation, mobbing, harassments etc. and suicide. Experienced scientists from the university centres for suicide research and their international network will be invited to participate in the research. Scientific experts from the universities public health centres, the maritime health research canters and the pedagogical institutes will be invited to carry out the planned research tasks and intervention programs. Tenders to be announced for the specific research tasks.

The research questions
The research questions focus on the seafarers´ knowledge, competencies, their needs for training, for quality life on board and how to prevent Public health illness. The research questions, the objectives and the methodology are specified in the research sections: systematic reviews, cross-sectional- and cohort studies and include the working- and living environment in the study populations.

The project objectives
For the review studies, the objectives are related to suicide, intervention methods, Public-health related risk factors and quality of life on board and in the maritime schools For the cross-sectional studies, the objectives are to study the prevalence of the risk factors, the relationship between the risk factors and the Public health indicators and to study the knowledge, skills and needs for training For the cohort studies, the objectives are to study which intervention methods are effective for Public health promotion among the youngest and the elderly seafarers

Project methodology
1. The review studies The review study on suicide is based on national-health register cohort studies on mortality that includes prevalences in shipping as compared with other workers. Intervention study reviews are based on cohort studies in shipping and cohorts of other workers. The review study on risk factors, include single risk factors and the combinations of different risk factors, especially interpersonal and organisational factors. The review study of learning materials, include studies that have shown to be useful and effective in Public health promotion in shipping and other settings. The PRISMA Statement will be adapted for systematic reporting of review studies.

2. The cross-sectional studies The studies will use validated standardized questionnaires. Students in 10-20 maritime schools in 10–15 countries will complete questionnaires before and after their sailing periods. Frequency and regression analysis will be used in accordance with the STROBE initiative for systematic reporting of the studies (13). The best methods for Public health promotion discovered in the review studies will be used. Methodological support is given in the Wikiversity learning sites; the Blue Risk Survey Program and validated standardized questionnaires will be used “Open Blue Risk Survey Program“ (Table 2). Surveys on knowledge, quality of life, attitude profile and the perceived training needs. Gap-analyse, will show potential areas, for in-depth guidance of the training programs.

3. The cohort studies Students from the maritime schools and academies will be enrolled in the cohort studies and complete surveys before and after being at sea. Study groups of 4–5 will form intervention study groups at the schools that will be educated in Public illness prevention and trained to give support to each other whenever this is needed and to keep in close contact. They will receive an educational course of 50 hours about maritime Public health and receive brush-up sessions together with experience sharing. Surveys on their knowledge before and after the courses and the tours at sea will be conducted. The selected education and training programs and materials will be based on the literature reviews and the epidemiological studies. The education and training programs will form the basis of a strategic primary prevention program together with the monitoring of the outcomes. Regression analysis will be used in accordance with the STROBE initiative for systematic reporting of the cohort studies.

Expected outcomes
The research project will be initiated creating the relevant knowledge base for the Blue Public Health Promotion Program. Based on this research, a comprehensive multi-faceted intervention program will be created, implemented and evaluated. The expected deliverables over 5-10 years are as follows:
 * 1)  A global network for maritime Public health promotion with the maritime unions, the maritime schools and the IMHA-Research network in 10–20 countries.
 * 2)  Different types of online training materials on Public health promotion will be developed.
 * 3)  Standard survey questionnaires to evaluate the training in the schools will be produced.
 * 4)  50 maritime schools/academies/universities in 15 countries will include compulsory training modules on maritime Public health promotion.
 * 5)  50 training courses on Public health promotion will be completed in the maritime schools
 * 6)  25 surveys will be executed among the students and the seafarers’ union members on the knowledge and skills to improve Public-health environment.
 * 7)  10 intervention cohort studies in different maritime schools will be completed
 * 8)  Internet-based information pages at ITF, Imha-Research pages and the network for the maritime schools the learning materials will be updated
 * 9)  10000–20000 maritime students will be trained every year and later all maritime students will be trained in Public health promotion and inspired for life-long learning.
 * 10)  A module book with instructions on how to use problem based learning with evaluations will be developed for use in the maritime academies
 * 11)  International peer reviewed articles to be published, see the next

Discussion
A global, evidence-based comprehensive program for Public health promotion at sea will be launched for the first time. The program will focus on the youngest seafarer´s knowledge, competencies, attitudes and needs in order to attract and to hold on them in shipping in the future. The aim is to educate and to empower primarily the youngest seafarers and the different segments of employees in shipping to reduce the Public health risks and to improve the quality of life on-board. The empowerment theories and the intervention mapping for developing evidence-based health education programs constitute the main applied theories , The health policy includes an active participation from all significant employee segments in shipping: the seafarer doctors, the seafarers, the maritime students, the Radio Medical doctors and the staff in the shipping companies. This is in order to improve the occupational health prevention based on scientific knowledge from surveys for all segments of the employees. The training programs will be tailored for each of the specific groups of employees based on the literature reviews and the surveys in all groups of employees. The education and training programs form the basis for the strategic prevention program followed by the monitoring of the outcomes. The need for new national and international guidelines and recommendations will be disclosed to minimise some risk factors that will else not be changed due to economic factors. Decisions in the shipping company, for example the manning on-board, numeration and the competencies of the seafarers, can have a significant impact on the quality of life and the Public health environment on board. Education and training of the whole shipping community is included in the health promotion programs with particular focus on the younger seafarers. The training teaching method will be mainly group work with problem solving. Their knowledge and attitudes will be surveyed and the gaps will form the basis of the Public health instruction to be provided. Decisions in the shipping company, for example the manning on-board, numeration and the competencies of the seafarers, can have a significant impact on the quality of life and the Public health environment on board. The youngest crewmembers are the most sensitive persons with great expectations, and they will form the future demands and criteria for the best working and living conditions at sea. It is worth to note that studies of Public health risk factors in shipping and no studies at all are seen for maritime schools.

Problem based – and lifelong learning

Problem-Based Learning (PBL) is a pedagogical approach that could be an excellent way of learning Public health promotion in the maritime academies. Learning is driven by open-ended problems with no one “right” answer,. Students work as self-directed, active investigators and problem-solvers in small collaborative groups (typically of about five students). Rather than having a teacher provide facts and then testing students ability to recall these facts via memorization, PBL attempts to get students to apply knowledge to new situations and are asked to investigate and discover meaningful solutions. The term “lifelong learning” is a term that aims to put learning in a broader perspective than schooling. Learning can be seen as something that takes place on an on going basis from our daily interactions with others and with the world around us. Modules on how to do problem based learning, group works and lifelong learning, will be developed to be used in the maritime schools Public health promotion courses. The aim is to enhance critical appraisal, skills in literature retrieval, evidence based health promotion that encourages continuous learning in a team environment. It is a special strength that the program will be performed in joint action among the ITF, the local union representatives, the IMHA-Research and the network of the maritime schools, including the cadets and the more experienced seafarers. The program for health promotion in shipping, like “The International Seafarers’ Welfare and Assistance Network” (ISWAN), does not include a scientific health promotion and evaluation like in this project. Neither are the program targeted at the youngest seafarers the maritime schools and the universities. Moreover, the previous programs were not based on sound scientific research, they had no evaluation of the effects, and they were not supported by the strongest workers’ organisation, the ITF. None of the existing maritime organisations, including the MLC 2006, the IMO, and the national maritime authorities, have launched evidence-based programs for Public health promotion in shipping.

This program is outstanding primarily by filling out the gap of Public health research based promotion, in the maritime industry. The basic target population is the youngest seafarers with the intention to train them at the maritime schools in Public health promotion. The training will be in groups of 3–5 with problem solving. The groups will stay in contact at the school and while out at sea the first times and later in life. They will be trained to identify the risk factors and how to solve the problems to maintain an attractive and healthy working environment on board to promote a supportive Public health environment. The network of ITF officers who are dedicated to improve the seafarers´ health and decent working conditions will lead the program in collaboration with the IMHA/Research group. The inclusion of the network of the universities through IMHA-Research is another important asset for an evidence-based Public health promotion network. A specific network for Public health in shipping organised by ITF with high quality teaching materials will allow for global support. This will promote relevant training of all sub-groups in the maritime industry.

Strengthening the network coordination


 * 1) The maritime schools and all other stakeholders will have access to the learning materials developed for global use. The web-based information pages at ITF together with the Imha-Research Wikiversity pages will be the main information platform. One of the participating universities with proved experience in similar international projects will undertake the finansial administration together with the ITF.  A steering group representing all Network groups will undertake the running coordination. One of the participating universities with proved experience in similar international projects will undertake the finansial administration together with the ITF. In kind assistance will be given in data collection for the research, training activity as part of the school´s curriculum and data collection as part of the students´ thesis for example.


 * 1) The maritime students will by themselves establish the strong networks through the social media and the maritime schools. The maritime school epidemiological cohorts are needed of scientific reasons but this will also enforce the networks. The millennium generation represent a vulnerable group for health and safety with specific demands for the Public health environment in shipping and they will know how to express their needs.


 * 1) The global network of national maritime unions will be established through the ITF with the objective for Public health promotion. This will strengthen Public health promotion internationally and pave the way for conducting long-term intervention cohort studies and training in Public health promotion for seafarers and all professionals in shipping.


 * 1) The network of the teachers in maritime schools will be established. All teachers in the maritime schools will be trained in Public health promotion. A permanent international Board of Maritime Schools will be established to disseminate the training materials throughout the entire shipping industry over the next decenias.


 * 1) The IMHA/research network with skilled researchers from the universities´ research centres in suicide prevention, public health and maritime medicine undertake the research projects, help to develop the training materials and be teachers in the training courses.
 * 1) The shipping companies, the unions, the maritime authorities and seafarers’ medical clinics will be asked to help with the list of mailers for the cross-sectional studies. They will also be asked to help develop the training materials and to develop training courses for their employees, some will be in kind.
 * 1) The international maritime organisations and the national governments will recommend that 1–2 % of the training in shipping is dedicated to training in Public health promotion. They will recommend that the external environments to be adequately adjusted for optimal Public health promotion in shipping.

Conclusions

 * 1)   The aim is to educate and to empower the youngest seafarers and all the different segments of employees in shipping in Public Health preventio
 * 2)   To reduce the health risks and to improve the quality of life.
 * 3)   The research program will enable for Public health promotion in the context of the international recommendations and national regulations.
 * 4)   Educate and empowerment the young seafarers through life-long- and problem oriented learning.
 * 5)   The policy implications emanating from the program will request adequate training programs in Public health tailored to all sub-sets of employees in the shipping industry.
 * 6)   The comprehensive descriptive and analytic research enable for a successful strategic Public health promotion, minimizing the Public health risk factors.
 * 7)   Political decisions and international guidelines are required to minimise the risk factors that will not otherwise be changed due to economic factors.