Occupational Epidemiology/Research tools/Research program for the Thesis topics/More detailed surveillance program description

Survey program of working environment and health of the maritime workers and their families
Developed by the Center for Maritime Health and Society, Institute of Public Health, Southern Danish University 2019 and intended to be executed as the MScPubHealth students thesis work.

Introduction
The monitoring of the health and working environment, which has been developed and implemented for rural occupations over the past 40 years, has not received the same attention in the maritime area. The blue industries have so far primarily investigated morbidity and mortality, but only to a lesser extent studies on health and safety at work. We will focus on the prevention of working environment and health at sea, including bullying and well-being. The KRAM factors (diet, smoking alcohol consumption and exercise), safety climate and the psychosocial environment are the key indicators that are planned to be monitored every 3-5 years together with data from injury and health exams registers. Further, the study data will be summed up within 4-6 years intervals so in the long term, the program will provide both snapshots and developmental trends in relation to the maritime worker's health and job retention. This contribute to developing and strengthening the Danish maritime sector's competence and competitiveness.

Purpose
To establish a program based on the MScPubHealth students final research work, the Thesis, for mapping of the maritime work environment and health factors. The study population include all men and women of all nationalities employed in seafaring, fishing, dockworking, offshore and their families, mentioned in the following as the maritime workers. To illuminate the working environment and health factors of consistency and development in relation to the regulations and job retention. To provide systematic and available current knowledge about the working environment in maritime employments. To use scientific methods that are well tested on land and which are supposed to be useful on maritime workers and their families nd thus can ensure relevant and valid results. To utilise the MScPubHealth students research thesis work to fill out the gap of surveillance for maritime workers.

Hypotheses
It is the hypothesis that the physical and psychosocial work environment vary in different types of martime workers and vary compared to shore workers with respective to work away from home, being at home and job retention.

Design
The goal is to include all the maritime workers and their families in repeated survey organised by their unions and professional organisations. The aim is to carry out repeated cross-sectional investigations at 4-5 year intervals and analyse the trends over time.

Seafarers
Studies over the latest thirty years show an over-frequency of cancer, cardiovascular disease diabetes and occupational accidents in seafaring compared to other occupatons (Poulsen RT et al 2014, Oldenburg M, 2014). The specific physical, chemical and psychological working environment factors on board also relate to the seafarers health conditions. (Oldenburg M et al. 2009 and 2010; Maclachlan M et al. 2012). Work-related diseases are primarily the result of physical work environment impacts in the form of noise and vibration, but also hearing damage and seasickness are well known (Jezewska M et al. 2006, Oldenburg M et al. 2009). Finally, infectious diseases, including tropical diseases, are a particular problem in certain geographical areas, where also strong exposure to ultraviolet radiation from the sun can cause sunburn and skin cancer. The quality of the mental work environment is dependent on a number of factors which have been carefully described in the past approx. 30 years (Levi L. 1989; Gigantesco A, Lega I. 2013). Ships with ongoing replacement of management present great challenges for both the manager and the employees and the culture at the workplace (Oldenburg M et al. 2009; Lodde et al. 2008). 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 (Elo AL 1996, Oldenburg M et al. 2009). Fatigue is considered a significant health and safety problem (Smith A et al. 2008). Jet lag after long flights for joining is described as part of this. (Malawwethanthri, K et al 2003; Allen P et al 2008).

Fishermen
The conditions of work in the fisheries sector are arduous with high rates of occupational non-fatal and fatal accidents. Logically, the prevention activities up till now mainly focussed on accident prevention with little attention to the emerging chronic diseases, especially diabetes and cardiovascular diseases related to the specific risk factors. 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 smallscale fishing. This needs to be taken into consideration in the prevention programs.

Port workers
Work on the ports is most often carried out outdoors in all kinds of weather, with exposure to a number of different work-related factors (Yukun Wang, Shuifen Zhan, Yan Liu & Yan Li) At a coal terminal, for example, a carbon dioxide emission that also threatens workers' health is measured (He XY ) 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 conducted as a Thesis by 2 public health students, SDU (Nanna of Sasha) 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 a good cooperation between colleagues were the reason for the feeling of security. Most of them were very satisfied with their work and they enjoy working hours. Most 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.

Offshore workers
A review of studies health and safety in the oil- and gas offshore industry concluded there is a need for more epidemiological studies in order to identify the specific areas that need attention for health and safety promotion (Jensen et al 2014). Besides the few epidemiological studies, there are plenty of administrative reports. However there is a problem with their quality compared to peer-reviewed publications. The methods are not always sufficiently described and the definitions of the injury inclusion criteria or the study populations are absent or unclear. Even where the research quality is good, it may be difficult to get copies of the reports. Another problem arises with reports written in languages other than English. The methodical problem hinders for a wide international use of the results and collaboration between the companies and nations and is an impediment to the establishment of international evidence based injury preventive initiatives.

Method
1.	Participants' health conditions Standardized questionnaires containing questions about past and present disease and symptomatology including self-assessment of health are used. This information can, if necessary, be supplemented or validated via public registers (the National Patient Register, the medicine register, etc.). 2.	Exposures in the work environment The self-perceived psychological and physical working environment is illuminated by means of a questionnaire. 3.	Lifestyle conditions on ships and at home. The participants' smoking habits, drinking habits, diet and exercise habits mapped by questionnaire fo r hold the participants habits both when sailing and when they are at home.

Content of the questionnaires
•	Age, position, area on the ship, •	Work planning and organization •	Safety culture on board •	security Management •	Instruction in safety •	Compliance with safety rules •	Attention to security •	Physical activity in free time on board •	Negative experiences in the workplace •	Noise, vibration and wet work •	Ergonomic loads •	Indoor climate on board •	Chemical conditions during work on board •	Sleep on board •	Your health, including dental health •	Possibly. The lan is about to stop working as a sailor •	Tobacco and alcohol on board and at home •	Food and drink out

Long-term perspectives:
After a successful pilot study, the idea is to: •	The shipping companies in cooperation with CMSS s launch similar studies •	CMSS ensures that the collected data is relevant and valid for use in prevention and for use in large-scale epidemiological studies •	Seahealth undertake not to provide any effort in the future and will therefore will not get ek s tra expenses. This is well-founded as Seahealth is not a research institution. •	It may be relevant to Seahealth convey r contact between interested companies and CMSS. It can e.g. be on permanent posting on the website and at the annual MSSM that the shipping companies are offered such monitoring via CMSS. •	CMSS To establish and develop a database of information collected on the arbejdsmi l ronmental exposures of the herds in all occupational categories, all areas on the ships, all ship types and sizes in the years ahead. •	CMSS wants the results to be presented at the annual MSSM in Nyborg in the years to come. •	CMSS collects data from several years to a job-eksponeringsmatricer (see below) for use in projec N gene by coupling to health records in cohort studies. •	CMSS collaborates with shipping companies and researchers in other countries on similar studies: Partly for the purpose of collecting data for the development of large exposure matrices. Partly for use in the development of international guidelines for the exposures and for use in large registers in star-based studies

Development of job exposure matrices at sea
In the field of work and environmental medicine, increasing demands are placed on the fact that reliable designations of exposure are also estimated in well-designed epidemiological studies. For example, by an assessment is ring of the causes of hearing loss and tinnitus, it is essential to estimate the actual exposure of the crew to noise over several years. This method is under rapid development by arbejdsmiljøforskni N gene from commercial country, but has not previously been used at sea. This, despite the fact that the method seems to be particularly useful for working environment on ships, since the construction of the various ship types globally is very similar. The possibility of a good international collaboration on descriptions of exposures is also right.

Participants and data collection
•	The participants are Danish seamen in several segments of the shipping industry •	The questionnaires are designed in Danish and completed electronically •	Mail addresses are obtained via shipping companies •	Certain segments of the merchant fleet are selected for the pilot study, e.g. container and tankers in long-distance traffic from several shipping companies. •	It will be possible to see contrasts between segments, e.g. larger and smaller ships and the various functions among the crews. •	It is aimed at 1000 people in the pilot study filling out the forms. •	Mail is sent with a link to the questionnaire in Danish •	Shakes e emitted 2 times. •	The scope of the respondents who do not wish to participate will be assessed.

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

Communication
An internal report is prepared for the Fund and 1- 2 scientific art sheets will be published in international scientific journals. The results will also be presented in trade journals and at conferences and be available on relevant websites from eg. Seahealth, Maritime Control l late, CMSS and the Danish Society of Maritime Medicine.

Pilot study
We have alreaey studies among prot workers, searafaeres wifes with good resuls