Maritime Health Research and Education-NET/Cohort protocols/Nordic Musculoskeletal Questionnaire(NMQ)Cohort Protocol

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Background
This protocol under development is intended to be used as a standard protocol for the completion of the Nordic Musculoskeletal Questionnaire(NMQ) cross-sectional studies in the MAHRE-Net. Actually, in Oct 2020 the European Union launches a campaign for musculoskeletal problems at the workplaces for all types of jobs. However as the maritime sector is relatively small, less than 1% of the population, this campaign will not really reach our maritime target groups --> LINK. There is evidence that significant musculoskeletal problems exist in all maritime occupations, and screening problems with the well-known NMQ tool is highly relevant. Global support in this article

Fishing
According to Dabholkar et al. fishermen have musculoskeletal problems with the most common joint involved in the low back and then followed by shoulder, knee, and hand. The ergonomic risk factor involved was found to be repeated pulling and throwing of the net as well as repeated bending forward action to lift a heavy load and transfer that heavy load. A cross-sectional survey of Danish fishermen revealed that the prevalence of pain was high for all musculoskeletal locations, being related to the perceived workload. Low back and shoulder pain was most common and encountered by 4/5 of the fishermen, while hand and neck pain were second most frequently experienced pain.

Seafaring
Carter et al. give attention to the needed health promotion in seafaring despite the lack of an extensive knowledge base on seafarer health the available information indicate that the predominant causes of serious illness and death in seafarers are broadly similar to those in the same socioeconomic group in their country of residence. Related to musculoskeletal diseases, they propose regular training to improve fitness that can reduce risks and rapid mobilization after some conditions such as low back pain, thus reducing long-term disability. There is a parallel need for sound systems of work to ensure that musculoskeletal demands from routine duties do not exceed accepted weight, reach, or frequency criteria. According to a descriptive study, musculoskeletal disorders (MSDs) are the second cause of illness among seafarers, after gastrointestinal disorders. It showed that non-officers were more likely than officers to experience MSDs (IRR=2.25), and that deck workers were more likely than engine workers to have MSDs (IRR=2.14).

Offshore workers
A cross-sectional study of 1,157 workers on offshore oil and gas installations asserted that neck, lower back, and knees were the most common areas of musculoskeletal pain among all job groups. However, workers from the drilling group experienced more musculoskeletal problems than those from the other workgroups, due to the physical load of activities. The significant prevalence of knee pain among the operation group was claimed to dominate because workers extensively walk on hard surfaces and climb stairs, while frequently being exposed to manual loading and carrying. In an offshore petroleum industry Morken et al., have found that upper limb pain (53%) and back pain (20%) were the most common work-related musculoskeletal disorders, and knee disorders dominated in the lower limb (16%). The described ergonomic risk exposures were high physical workload (38%), repetitive work (26%), and walking on hard surfaces/climbing stairs (10%).

Port workers
Work on the ports is most often carried out outdoors in all kinds of weather, with exposure to several different work-related factors Diesel exhaust emission that also threatens workers' health is measured Noise is one of the major occupationally harmful factors and in other areas, there is not only noise but also exposures to various harmful chemicals, including when working with containers. A cross-sectional study among port workers in three cities in Denmark, using both quantitative and qualitative methods, found that the port workers feel secure about the safety of their workplace and that good cooperation between colleagues was the reason for the feeling of security. Most of them were very satisfied with their work and they enjoy working hours. Most of them did not find it stressful to be unemployed where there is no guarantee of work (and half had never felt stressed). The working environment of port workers has been investigated quite sporadically internationally and repeated surveys are needed. According to a cross-sectional study conducted by Zolkafi and Zain, the port workers’ age, different types of work categories, working experience, and body mass index (BMI) were associated with the prevalence of musculoskeletal disorders. For example, the young age group (21- 39 years) of port workers were 9 times more likely (95% CI 1.83- 40.55) to suffer from back injuries, however, the older age group (40- 55 years old) had a 5 times higher chance of getting hand injury and a 2 times higher chance of getting elbow injury. 75% (n=68) of total studied port workers who referred to physiotherapy department for rehabilitation purposes constituted crane operator category, while the small percentage comprised office and maintenance category. In a retrospective study conducted in a seaport in the South of Brazil, Almeida et al. found that lower back pain was the most frequent MSD, affecting more wharf workers and longshoremen. They claim that the occurrence of work-related MSDs is due to labor activities requiring the manual handling of heavy loads, using frequently equipment such as, vehicles, tractors, and mechanical shovels, which expose workers to whole-body vibration. Moreover, working tasks are performed in a sitting position, with arms maintained above shoulder-level, and the lack of regular exercise all contribute to the development of WRMSDs.

Divers
A Norwegian cross-sectional study of 2,848 professional divers Flatmo et al. established that 48.5% of the divers reported having had musculoskeletal complaints lasting at least 3 months during the last 12 months. The risk of musculoskeletal complaints was significantly higher among divers working in the quay/construction industry versus divers not working in this industry, and among divers who had experienced decompression sickness (DCS). Similarly, a higher risk was found among divers doing construction, inspection, pipelaying, blasting, and welding, working with vibrating and/or rotating tools, and other physically demanding work.

Objectives
To provide systematic and current knowledge about the ergonomic working environment for seafarers on ships from different countries. To use scientific methods that are well tested on land in many countries 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 Health Promotion Program. The goal is for everyone to benefit from the project, both for the seafarers and for the companies. 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

Hypotheses
It is the aims to test the hypothesis that the working environment of the ships differs by ship type and size, area of work, job type of the ship, and other industries onshore. Further that there is a connection between the working environment, lifestyle onboard and home, and the health and welfare of the crews.

Methods
An epidemiological, cross-sectional-based study will be performed by the use of mail distributed questionnaires about the subjective environment including self-assessment of health are used. The content of the questionnaires is demographic information about the person for the students and about the ship for the seafarers. So we have two versions of the questionnaire one for the students and one for them when they are in practice as seafarers and later employed seafarers. We include screening for smoking, height, and weight for BMI related to Chronic diseases prevention in order to stay in line with the DiMoPEx (CA 15129)

Questionnaires
Questionnaire for maritime students Questionnaire for seafarers(NMQ)

Data collection
Probably the most difficult step in this study was to keep the personal mobile data security and so we choose to use Whatsapp and e-mail in order to avoid any concerns about abuse in the port workers. To remember the mobile numbers only return to the union that sends them out, not to the researchers. But also because not all use e-Mail very often. The best choice to invite would be to use WhatsApp that nearly all young and older persons have In Latin America. But then there was the problem of how to send reminders because the Google forms only can do that automatically by using the mail addresses. So we agreed on the best way to send it out by WhatsApp. After probably 20% of responders, the reminders would be sent out by Whatsapp to all again. In the message to non-responders and responders, we thank those who have answered, that their response is well received, and please look away from this reminder. For those who did not answer we ask them to respond of importance for the whole group.

Long-term perspectives
After a successful study in the Maritime University classes, the idea is to repeat the questionnaire in 2-3 years with the same students now working at sea after agreement with the universities. Studies with other themes like Safety Culture can be done with the Maritime Universities.

Further, the aim is to collaborate with other countries, Iceland that have shown interest in the same type of study. An identical questionnaire will be used with the possibility to compare between the countries. Our target group of maritime workers includes seafarers, fishermen, port workers, off-shore workers, and seafarers’ wives. That means we will try to do similar studies with the other target groups over time.

We propose a program with methodological training support and supervision of the students’ research projects, their graduation Thesis.

This initiative will contribute to important parts of the UN Sustainable Goals, especially Goal 3: Good Health and Wellbeing especially for the maritime workers, and Goal 14: Life below water with observations on compliance to keep the garbage on board and visible pollutions at sea in the monitoring. Monitoring over many years con contribute to new valuable knowledge as example in this study :Trends of Chronic backpain among adolescents Due to the selection out of the occupation in the older age-groups, The healthy worker effect valid comparisons can be done for the youngest generations.

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 anonymous form in the universities. All data will be stored in a special database to use data up following studies later. The Data Inspectorate to be informed and current legislation to be complied with.

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

Dissemination of results
The results will also be presented in the Maritime Company News and at conferences and be available on relevant websites from e.g….. In case the student wants to go further a scientific article will be published in an international scientific journal.

Use the results for prevention
This questionnaire was developed as a tool for workplace assessment of the ergonomic work environment. When the employees have filled in the questionnaire, the overall results for the workplace and for each of the departments are calculated. There are also questions on how the workers would propose to make the workplace as safe and healthy as most possible. If the survey seems to indicate some specific problems with the work environment, the work environment committee at the workplace 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 to develop a guide for understanding and interpretation of the results. Links to guidelines for prevention:

https://www.osha.gov/ergonomics

https://osha.europa.eu/en/tags/musculoskeletaldisorders

Pilot study
Pilot studies are carried out among 20-30 students in maritime universities

Work plan

 * 1) Agreement with maritime schools and the students
 * 2) Questionnaire collection program ready
 * 3) Pilot test of the Form
 * 4) Mail lists established
 * 5) Mail with link to the questionnaire in English
 * 6) Reminder send twice with 2 weeks between
 * 7) Data analysed and tables prepared
 * 8) Report-Thesis- publication
 * 9) Prevention plan