Maritime Health Research and Education-NET/Cohort protocols/GHQ12 Cohort protocol

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GHQ12-cohort protocol
The psycho-social study environment in the maritime universities and on board the ships.

Background
Stress among students is well known but a suspected excess study related to stress and the GHQ12 has not so far been used to evaluate the stress among maritime students. The GHQ12 survey in the maritime schools completes part of the diagnostics of a global mental health program at the schools and workplaces, also related to the WHO program: The WHO health promoting school-framework for improving the health and well being.There is little knowledge on mental health, bullying, sexual harassment, smoking, alcohol, among the maritime students. Better knowledge is needed to improve the educational environmental conditions for the maritime students and the seafarers to inspire them to stay in the profession.

For the maritime students
To evaluate the mental health, bullying, sexual harassment, smoking, alcohol, among and the maritime students and their evaluation of the precautions taken by the maritime schools

For the seafarers
To evaluate the well-being of the seafarers and the evaluation of the precautions taken by the shipping companies. It is very important to correctly assess the stress risk of these sea workers. In fact, the role of the bio-humoral influences of stress on the immune system and not only on the psychological structure of workers and therefore on the organization of work is well known.

Methods
A sample of seafarers is asked to complete the General Health Questionnaire (GHQ) and to evaluate the stress precautions taken on board. This is a pilot study and lays the foundations for further larger studies, always based on questionnaires, or even on other methods of assessing work-related stress, also with the search for laboratory-level stress markers. The questionnaires are on mental health, bullying, sexual harassment, smoking, alcohol, and the students ‘suggestions on how to create an inspiring learning environment.

Expected results
Seafarers have increased work-related stress levels compared to shore workers due to the specific work situation. However, we expect that someone needs more support, not only in terms of security measures but also on a psychological level. if the situation of excess risk-related work stress is confirmed, it would be interesting in the future to investigate the stress of mariners also from a bio-humoral point of view to have a more objective point of view. There is a need to integrate stress prevention in the maritime universities and these surveys will be part of the learning program.

BACKGROUND
This protocol under development is intended to be used as a standard protocol for the completion of the GHQ12 cross-sectional studies in MAHRE-NET. The GHQ12 survey in the maritime schools is part of the diagnostics in a global mental health program at the maritime workplaces Jensen O, Canals M & A Bygvraa D. 2017 and Jensen et al. 2019 The seafaring employees often face more difficult working conditions in the sea than the employees working on the land. Their mental health is affected by the environment in which they live, often coupled with long working hours that contribute to stress, anxiety, loneliness, depression, and suicide. This proposal seeks to improve the seafarers’ mental health by introducing a comprehensive, evidence-based global maritime mental health promotion program that attracts the youngest seafarers to choose and to stay in the job. Methods: The theories on empowerment, life-long- and problem-oriented learning with the inclusion of all stakeholders form the theoretical background. Our main 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. The specific physical, chemical and psychological working environment factors on board also relate to the seafarer's health conditions (1)(2)(3). The quality of the mental work environment is dependent on several factors which have been carefully described in the past approx. 30 years (4) (5) (1). Ships with ongoing replacement of crew present great challenges for both the manager and the employees and the culture at the workplace (6). During navigation, the sailors are often moved to very small working groups, where conflict management can be difficult. The requirements are very variable, the nature of the work requires considerable discipline and thus less self-control. Support from superiors and colleagues can be made difficult by the fact that crews come from many different nationalities. These conditions can lead to experienced stress and burnout (7) (1). Fatigue is considered a significant health and safety problem [14]. Jet lag after long flights for joining is described as part of this (8). (12) In the latest research Helen Sampson, director of Cardiff University's Seafarers International Research Centre, said that seafarers working on cargo ships "experience very little happiness on board". (9) She said there was evidence recent-onset psychological disorders were increasing among serving seafarers but 55% of employers said they had not introduced any policies or practices to address mental health for a decade. Seafarers' mental health and well-being found that internet access would make the most significant contribution to improving mental health and well-being together with other key recommendations underscored in the report and the BBC News (Seafarers Mental Health and Well-being Nov. 2019). Jensen and Oldenburg conclude that because of many stressors on board, and the lacking respective education, there is a strong need to integrate stress management in the maritime educations especially for officers Guidelines for prevention https://www.copsoq-network.org/assets/Uploads/COPSOQ-network-guidelines-an-questionnaire-COPSOQ-III-131119-signed.pdf Authors "soft guidelines" page 7, start with: "Never start a psychosocial risk assessment unless there is a clear intention of taking action if indicated". The psychological stress in seafarers resulting from the Covid pandemic has already been investigated by our MAHRE group with GHQ 12 test. In a small pilot study, it emerged that the category of seafarers did not suffer additional stress from the international situation and that they feel safe at work (10).

/Invitation to the schools/
The European community underscores the need to take more attention to mental health in all parts of the communities. For the youth and the adults the policy recommendations include 1. Strengthen information and research on mental health and well-being among children and adolescents. a. Establish a solid information base to have a detailed epidemiological frame of the mental health among children and adolescents and evidence on interventions. b. Provide information on coverage and outcomes of interventions, including for groups at higher risk as well as on the size, impact, cost, and potential economic savings of appropriate interventions. c. Carry out a mapping and analysis of existing screening tools for early identification, from the first developmental stages, of mental health disorders and poor well-being among children and school populations. d. Examine the potential to increase access to information and services through the use of web-based technologies (e-mental health) to promote mental well-being and the prevention of mental and behavioral disorders. The surveys in the maritime schools complete part of the diagnostics of a global mental health program at the schools and workplaces in the WHO health-promoting school-framework for improving the health and well being ,

Objectives
To provide systematic and current knowledge about the psychosocial working environment for students at the maritime universities. To use scientific methods that are well tested on land and which are supposed to be useful on the ships and thus can ensure relevant and valid results.

Scientific aims
The aim is to help to create an evidence-based Health Promotion Program for maritime workers and the schools. The goal is for everyone to benefit from the project, both for the seafarers and for the company. The project focuses on good psycho-social wellbeing at the University, onboard and in the company with the benefits for all parties the students, teachers, workers, shipping companies, and the community. The scientific aim is to produce data and publications that convey new knowledge of high validity based on the newest scientific principles for the conduct of studies in peer-reviewed publications.

Occupational stress and depression etiological models
Due to the high prevalence and severe consequences, stress and depressive disorders provide an important challenge to occupational and public health. The literature about etiological models for the development of occupational stress and depression is scarce specifically for GHQ12. More in general for occupational stress and depression, the classical model is the Karasek job control and demand model Occupational stress and depression has been described in terms of an interaction between the predisposing, precipitating, and perpetuating factors. Danasekaran, Raja, and Ravivarman Govindasamy have given a list of suspected etiological risk factors for anxiety and depression According to Siegrist chronic psychosocial stress at work, demand-control, and effort-reward imbalance, is a modifiable risk factor. Findings from 12 reports indicate a rather consistently elevated odds ratio of about 1.8 of depression among men and women who were exposed to high demand and low control at work or who spent high efforts in combination with low rewards received in turn.

Methods
An epidemiological, cross-sectional-based study will be performed by the use of mail distributed general Health Questionnaires (GHQ12) are used. The content of the questionnaires is demographic information about the person, questions about the psychosocial work environment, about the way your work affects your private life and family, It is in line with the Danish Maritime Leaders' wishes. Maritime Schools are invited to participate. Standardized questionnaires are sent to the students about smoking, alcohol, mental health, bullying, sexual harassment and suggestions for improving of the education. The students can use it as their final study thesis. The managers can together with the students, use the results to propose concrete improvements to the education and contribute to creating interest among young people in entering the maritime profession. The same model can be used on the ships. If the survey seems to indicate problems with the psychosocial work environment, the work environment committee or other relevant actors at the university should discuss how to act on the basis of the results. If help from the outside is needed, the workplace may contact consultants, the Labour Inspection, or relevant organizations.

GHQ12 For maritime students

GHQ12 For seafarers and practicants

Long-term follow-up of the cohort
After a successful baseline study, follow-up will be done in 1-4-year intervals of the same participants. A low participation rate can be a problem. Further, the aim is to collaborate with other countries. Iceland that have shown interest for the same type of study. An identical questionnaire will be used with the possibility to compare between the countries.

Data processing
Data is transferred to electronic processing during the investigation. Standardized statistical methods will be used using the latest data processing SPSS program. Data will be handled under strict confidentiality in an anonymous form. All data will be stored in a special database to use data up following studies later. The current legislation is complied with.

Data analysis
Each of the Goldberg’s General Health Questionnaire (GHQ12) items has four answer options: 1) more than usual, 2) as usual, 3) less than usual, and 4) much less than usual describing mood states. Using the Likert code method 0-1-2-3 gives a total score range of 0–36. The Likert sum scores were classified as 0–14 (no problems), 15–19 (starting problems), and 19–36 (serious problems). Analyses of the Likert scores can be divided into two groups: group 1: Likert score 0–14 no problems, (no action needed) and group 2: Likert score 15–19 starting problems (included 2 with Likert score 20–36: serious problem). Cut-off-point of Likert scores for the GHQ-12 has been proposed in mental health studies of working people. The optimal cut-off points that can serve as a tool for identifying persons with a mental disorder were established at the level of 2/3 points for GHQ-12 The explanation is that 2/3 of maximum scores = 36 in the Likert code method 0-1-2-3 with a cut-off point of 24. Lundin et al. y Pesel et al. estimated the beginning of problems at 12+ and 14+, respectively Excel methods to recode the questions

Ethical requirements
Since the study does not involve blood sampling, and since participation in the study is completely voluntary after informed consent, the study does not involve ethical problems. All data are treated according to the Act on the duty of confidentiality, and the guidelines for good epidemiological practice will be followed. The participants' anonymity will be ensured in all ways and this will be apparent from the project description and the form. It will be ensured that the electronic form is locked so that the information cannot be seen by anyone other than the researchers. More detailed information SDU Guide for data safety

Dissemination of results
The students finish his/her Thesis which will also be handed over to the UMIP. The results will also be presented in the Maritime News and at conferences and be available on relevant websites from e.g. In case the student wants to go further support to write a scientific article will be given.

Work plan

 * 1)  	Agreement with the universities and the students
 * 2) 	Questionnaire translations and development
 * 3) 	Pilot test
 * 4) 	Mail lists
 * 5)  	Mail send out with link to the questionnaire
 * 6)  	Data analysed and tables ready
 * 7) 	Thesis prepared (and possibly an article)
 * 8)   Prevention plan